Health Information Technology Projects Research Articles

Representative Participation in a Large-Scale Health IT Project

User involvement is widely recognized as best practice in the development of information technology (IT) systems. In large-scale IT projects, the involvement of users and other stakeholder groups is typically in the form of representatives, as opposed to the direct (in-person) participation characteristic for smaller projects. The potential new sharing of power that representative participation entails vis-à-vis direct stakeholder involvement, and the implications of such a shift, are an important discussion in the context of participatory design. This paper extends and adds to previous work on this subject. Drawing on stakeholder interviews conducted as part of a case study of an electronic health record implementation project in Norway, this paper seeks to describe and analyze problems that can arise with representative participation in a large-scale project. Our focus is on an observed decline of interaction between health professionals participating actively in the project and their advisory units consisting of colleagues without a formal project role. The paper describes how the project’s structural arrangements might explain this decline. The paper also describes how the participating health professionals’ involvement of the advisory units at regular intervals early in the project (broad involvement) was replaced by more ad hoc and competence-oriented approaches (narrow involvement). We further use the organizational structure of democracies as the basis for two analogies, (I) participants-as-political-representatives and (II) participants-as-technocrats. The observed decline in interaction between the participating health professionals and their advisory units can be seen as a transition in role from user representative to technocrat. Generalizing from the case, we suggest that (1) a project’s structure strongly affects the possibilities of participating users to consult other users (e.g., non-participating colleagues) about issues concerning the design solution, (2) a project’s structure conditions the role of participating users and who, or what, they represent, and (3) representative participation requires rethinking a project’s structure.

Understanding dyadic promoter-stakeholder relations in complex projects

In this study, we propose a Bilateral Double Motive framework of stakeholder cooperation in complex projects. The framework analyses and explains dyadic promoter-stakeholder relationships at a micro level by acknowledging both transactional and relational motives. We demonstrate the framework’s usefulness by illustrating its explanatory power in two instances of cooperation and two of non-cooperation within two health information technology projects. The study contributes to project management theory through its combined focus on transactional and relational motives. Further, the study contributes to practice by providing a tool for planning and evaluating cooperation in health Information Technology projects and similar complex multi-stakeholder environments.

Assessing Health Data Security Risks in Global Health Partnerships: Development of a Conceptual Framework.

BackgroundHealth care databases contain a wealth of information that can be used to develop programs and mature health care systems. There is concern that the sensitive nature of health data (eg, ethnicity, reproductive health, sexually transmitted infections, and lifestyle information) can have significant impact on individuals if misused, particularly among vulnerable and marginalized populations. As academic institutions, nongovernmental organizations, and international agencies begin to collaborate with low- and middle-income countries to develop and deploy health information technology (HIT), it is important to understand the technical and practical security implications of these initiatives.ObjectiveOur aim is to develop a conceptual framework for risk stratification of global health data partnerships and HIT projects. In addition to identifying key conceptual domains, we map each domain to a variety of publicly available indices that could be used to inform a quantitative model.MethodsWe conducted an overview of the literature to identify relevant publications, position statements, white papers, and reports. The research team reviewed all sources and used the framework method and conceptual framework analysis to name and categorize key concepts, integrate them into domains, and synthesize them into an overarching conceptual framework. Once key domains were identified, public international data sources were searched for relevant structured indices to generate quantitative counterparts.ResultsWe identified 5 key domains to inform our conceptual framework: State of HIT, Economics of Health Care, Demographics and Equity, Societal Freedom and Safety, and Partnership and Trust. Each of these domains was mapped to a number of structured indices.ConclusionsThere is a complex relationship among the legal, economic, and social domains of health care, which affects the state of HIT in low- and middle-income countries and associated data security risks. The strength of partnership and trust among collaborating organizations is an important moderating factor. Additional work is needed to formalize the assessment of partnership and trust and to develop a quantitative model of the conceptual framework that can help support organizational decision-making.

Nursing Informatics in Israel From a Historical Perspective.

The field of nursing informatics is expanding in Israel, which is known as a start-up nation. This study is a systematic literature review aimed to obtain a historical perspective of the Israel's nursing informatics development. To study how nursing informatics has evolved in Israel over the past 20 years, we analyzed two major issues: (1) the development of the nursing informatics field over these years; and (2) nursing informatics studies that were carried out by nurses. The main criteria for choosing these studies were: (1) nursing informatics research conducted in Israel; (2) investigated by nurses; and (3) published in academic international journals, including PhD dissertations. Thirty studies were located, and two main issues were identified: nurse managers who were engaged in health information technology were not recognized as nursing informatics practitioners, and a minority of nurses performed nursing informatics researches. Although many health information technology projects were and are performed in Israel, the nursing informatics field is not fully recognized by Israeli nurses. Therefore, it is essential for Israeli nurses to understand the importance of advancing the nursing informatics body of knowledge, which will give nurses the authorization to become influential as health information technology professionals in areas such as health education, practice, and research-for the benefit of patients.

Infobuttons for Genomic Medicine: Requirements and Barriers.

The study aimed to understand potential barriers to the adoption of health information technology projects that are released as free and open source software (FOSS). We conducted a survey of research consortia participants engaged in genomic medicine implementation to assess perceived institutional barriers to the adoption of three systems: ClinGen electronic health record (EHR) Toolkit, DocUBuild, and MyResults.org. The survey included eight barriers from the Consolidated Framework for Implementation Research (CFIR), with additional barriers identified from a qualitative analysis of open-ended responses. We analyzed responses from 24 research consortia participants from 18 institutions. In total, 14 categories of perceived barriers were evaluated, which were consistent with other observed barriers to FOSS adoption. The most frequent perceived barriers included lack of adaptability of the system, lack of institutional priority to implement, lack of trialability, lack of advantage of alternative systems, and complexity. In addition to understanding potential barriers, we recommend some strategies to address them (where possible), including considerations for genomic medicine. Overall, FOSS developers need to ensure systems are easy to trial and implement and need to clearly articulate benefits of their systems, especially when alternatives exist. Institutional champions will remain a critical component to prioritizing genomic medicine projects.

Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department.

The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

How to Assess Success of HIT Project Management: An Example of the Use of the Common Assessment Framework (CAF).

The purpose of this study was to assess the project management of a national health information technology project focused on developing digital health care services. An e-questionnaire was sent at the end of the development project, and 93 experts (18%) from five university hospitals responded. The questionnaire was based on the Common Assessment Framework (CAF) to identify management success and also to get an overview of the project's performance. The questionnaire contained 11 background variables and 17 Likert scale items in five themes on leadership, strategy and planning, people, partnerships and resources, and processes, and one open-ended question. After analysis using descriptive statistical methods, the results showed that, overall, participants felt confident about management of the project. Criticism focused on the distribution of resources and lack of knowledge about the status of development activities in other hospitals. The CAF enablers criteria revealed subjects for further development.

Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study.

BackgroundThe Kenyan government, working with international partners and local organizations, has developed an eHealth strategy, specified standards, and guidelines for electronic health record adoption in public hospitals and implemented two major health information technology projects: District Health Information Software Version 2, for collating national health care indicators and a rollout of the KenyaEMR and International Quality Care Health Management Information Systems, for managing 600 HIV clinics across the country. Following these projects, a modified version of the Open Medical Record System electronic health record was specified and developed to fulfill the clinical and administrative requirements of health care facilities operated by devolved counties in Kenya and to automate the process of collating health care indicators and entering them into the District Health Information Software Version 2 system.ObjectiveWe aimed to present a descriptive case study of the implementation of an open source electronic health record system in public health care facilities in Kenya.MethodsWe conducted a landscape review of existing literature concerning eHealth policies and electronic health record development in Kenya. Following initial discussions with the Ministry of Health, the World Health Organization, and implementing partners, we conducted a series of visits to implementing sites to conduct semistructured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation.ResultsThis case study describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital information technology infrastructure, training users, and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of sociotechnical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya.ConclusionsImplementing electronic health record systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing, but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. Strategies such as creating local support teams, using local development resources, ensuring end user buy-in, and rolling out in smaller facilities before larger hospitals are being incorporated into the project. These are positive developments to help maintain momentum as the project continues. Further integration with existing open source communities could help ongoing development and implementations of the project. We hope this case study will provide some lessons and guidance for other challenging implementations of electronic health record systems as they continue across Africa.

PP15 Incorporating Participatory Design Approaches Into HTA

Introduction:To address local workability, cross-setting variation, and clinician and patient perspectives, health technology assessment (HTA) practitioners and health system decision-makers incorporate varying forms of qualitative evidence into evaluations of novel health technologies. Employing principles and methods from long-established sociotechnical fields such as participatory design (PD) may help HTA teams in the production of formal, rigorous ‘practice-based evidence’.Methods:We draw on a theoretical review of foundational PD literature and experiences using PD for a large-scale health information technology project to summarize principles and strategies for the effective introduction and evaluation of new technologies in healthcare.Results:HTA may benefit from observing some of the core commitments of PD: (i) Ensuring that technologies enhance rather than detract from the quality of working life; (ii) Fostering democratic engagement in the implementation and evaluation of technologies; and (iii) Proceeding via direct partnership with technology users. These are practical commitments stemming from the recognition that technology implementation entails re-configuring existing practices and social arrangements. The experts of this existing milieu are the people on the ground, who may reject or underutilize technologies that they perceive as impractical, ill-adapted to their needs, or having negative consequences on their work. At the same time, PD recognizes that local activities occur within larger systems and that effective technology introduction also requires attention to macro-politics (e.g. governance challenges, competing priorities). PD employs a diversity of methods (e.g. participant observation, focus groups, workshops, interviews) to develop evidence that is holistically informed.Conclusions:Many of the challenges that HTA faces, both in terms of evidence production and translation, have been encountered before in PD. Given that decision-making around health technologies necessarily involves consideration of many forms of qualitative evidence, there is value in producing and evaluating such evidence in carefully designed manner – a challenge to which fields like PD can lend a wealth of experience.

Bridging clinical researcher perceptions and health IT realities: A case study of stakeholder creep

PurposeWe present a case report detailing a challenge in health information technology (HIT) project implementations we term “stakeholder creep”: not thoroughly identifying which stakeholders need to be involved and why before starting a project, consequently not understanding the true effort, skill sets, social capital, and time required to complete the project. MethodsA root cause analysis was performed post-implementation to understand what led to stakeholder creep. HIT project stakeholders were given a questionnaire to comment on these misconceptions and a proposed implementation tool to help mitigate stakeholder creep. FindingsStakeholder creep contributed to an unexpected increase in time (3-month delayed go-live) and effort (68% over expected HIT work hours). Four main clinician/researcher misconceptions were identified that contributed to the development of stakeholder creep: 1) that EHR IT is a single group; 2) that all EHR IT members know the entire EHR functionality; 3) that changes to an EHR need the input of just a single EHR IT member; and 4) that the technological complexity of a project mirrors the clinical complexity. HIT project stakeholders similarly perceived clinicians/researchers to hold these misconceptions. The proposed stakeholder planning tool was perceived to be feasible and helpful. ConclusionsStakeholder creep can negatively affect HIT project implementations. Projects may be susceptible to stakeholder creep when clinicians/researchers hold misconceptions related to HIT organization and processes. Implementation tools, such as the proposed stakeholder checklist, could be helpful in preempting and mitigating the effect of stakeholder creep.

Lessons Learned from Participatory Design in Dementia Care: Placing Care Partners at the Centre.

In this paper we analyze the participatory design (PD) process of a health information technology (HIT) project. This project, AToM was situated in dementia care and involved partners from academia, industry and care. The analysis specifically focuses on the role of the care partners in the PD process. We will show that the conditions to enable 'good participatory design' were not fully met and we present a set of actions to prevent this in future HIT projects. Central to our recommended approach is placing the care partners at the centre of the PD project.

What is the extent of research on the characteristics, behaviors, and impacts of health information technology champions? A scoping review

BackgroundAlthough champions are commonly employed in health information technology (HIT) implementations, the state of empirical literature on HIT champions’ is unclear. The purpose of our review was to synthesize quantitative and qualitative studies to identify the extent of research on the characteristics, behaviors, and impacts of HIT champions. Ultimately, our goal was to identify gaps in the literature and inform implementation science.MethodsOur review employed a broad search strategy using multiple databases—Embase, Pubmed, Cinahl, PsychInfo, Web of Science, and the Cochrane library. We identified 1728 candidate articles, of which 42 were retained for full-text review.ResultsOf the 42 studies included, fourteen studies employed a multiple-case study design (33 %), 12 additional articles employed a single-case study design (29 %), five used quantitative methods (12 %), two used mixed-methods (5 %), and one used a Delphi methodology (2 %). Our review revealed multiple categories and characteristics of champions as well as influence tactics they used to promote an HIT project. Furthermore, studies have assessed three general types of HIT champion impacts: (1) impacts on the implementation process of a specific HIT; (2) impacts on usage behavior or overall success of a specific HIT; and (3) impacts on general organizational-level innovativeness. However the extent to which HIT projects fail even with a champion and why such failures occur is not clear. Also unclear is whether all organizations require a champion for successful HIT project implementation. In other words, we currently do not know enough about the conditions under which (1) a health IT champion is needed, (2) multiple champions are needed, and (3) an appointed champion—as opposed to an emergent champion—can be successful.ConclusionsAlthough champions appear to have contributed to successful implementation of HIT projects, simply measuring the presence or absence of a champion is not sufficient for assessing impacts. Future research should aim for answers to questions about who champions should be, when they should be engaged, what they should do, how management can support their efforts, and what their impact is given the organizational context.

Uptake of nutrition informatics in Australia compared with the USA

AbstractAimTo determine the method and extent of health information technology (HIT) utilisation, roles in relation to HIT in the workplace and perceived barriers and benefits of HIT by dietitians in Australia and provide a comparison with dietitians in the USA.MethodsA survey adapted from the 2011 Academy of Nutrition and Dietetics (Academy) was utilised and circulated electronically to Dietitians Association of Australia members and advertised through a professional nutrition website in 2013. The survey encompassed 25 questions on computer access and use, data sources, experience using HIT, organisational involvement and perceived barriers and benefits to HIT. Descriptive statistics, independent t‐tests, chi‐square tests and z‐tests were computed to investigate and compare responses from the 2013 Australian and 2011 Academy surveys.ResultsThe survey completion rate represented 14.5% of Dietitians Association of Australia members (747) and 5% of Academy members (3342). The Australian and Academy respondents reported similar high levels of comfort using technology, awareness of workplace HIT benefits (such as enhanced time management and improved ability to access data) and low levels of organisational involvement. However, there were a significantly greater number of Academy organisations utilising electronic health records (P < 0.05), and significantly more Academy respondents (55%) reported ‘no barriers’ to using HIT compared with Australians (37%) (P < 0.05).ConclusionsEducational programmes will be central to ensuring dietitians are equipped with technology and information management skills required to be involved in and make informed decisions about dietetic‐related HIT projects as these will soon be fundamental to dietetic practice.

IT-enabled Community Health Interventions: Challenges, Opportunities, and Future Directions.

Rising health information technology (HIT) adoption and the increasing interoperability of health data have propelled the role of IT in community-wide health transformations. Disseminating the challenges and opportunities that the early adopters of community-wide HIT interventions have experienced is critical for empowering the growing demand for community-based health systems. This special issue of eGEMs addresses that need. This issue includes a variety of community-based HIT projects covering topics such as governance, informatics, and learning health systems. These projects represent a diverse set of stakeholders, a wide selection of data sources, and multiple information platforms to collate or exchange data. We hope that this special issue of eGEMs will be the first of several future issues dedicated to community-wide HIT transformations.

Managing collaboration across boundaries in health information technology projects.

One reason that it is so difficult to build electronic systems for collecting and sharing health information is that their design and implementation requires clear goals and a great deal of collaboration among people from diverse social and occupational worlds. This paper uses empirical examples from two Australian health informatics projects to illustrate the importance of boundary objects and boundary spanning activities in facilitating the high degree of collaboration required for the design and implementation of workable systems.

Prehospital electronic patient care report systems: early experiences from emergency medical services agency leaders.

BackgroundAs the United States embraces electronic health records (EHRs), improved emergency medical services (EMS) information systems are also a priority; however, little is known about the experiences of EMS agencies as they adopt and implement electronic patient care report (e-PCR) systems. We sought to characterize motivations for adoption of e-PCR systems, challenges associated with adoption and implementation, and emerging implementation strategies.MethodsWe conducted a qualitative study using semi-structured in-depth interviews with EMS agency leaders. Participants were recruited through a web-based survey of National Association of EMS Physicians (NAEMSP) members, a didactic session at the 2010 NAEMSP Annual Meeting, and snowball sampling. Interviews lasted approximately 30 minutes, were recorded and professionally transcribed. Analysis was conducted by a five-person team, employing the constant comparative method to identify recurrent themes.ResultsTwenty-three interviewees represented 20 EMS agencies from the United States and Canada; 14 EMS agencies were currently using e-PCR systems. The primary reason for adoption was the potential for e-PCR systems to support quality assurance efforts. Challenges to e-PCR system adoption included those common to any health information technology project, as well as challenges unique to the prehospital setting, including: fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating with existing hospital information systems, and unfunded mandates requiring adoption of e-PCR systems. Three recurring strategies emerged to improve e-PCR system adoption and implementation: 1) identify creative funding sources; 2) leverage regional health information organizations; and 3) build internal information technology capacity.ConclusionEMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts; however, adoption and implementation of e-PCR systems has been challenging for many. Emerging strategies from EMS agencies and others that have successfully implemented EHRs may be useful in expanding e-PCR system use and facilitating this transition for other EMS agencies.

HIT or Miss – studying failures to enable success

Health information technology (HIT) is intended to improve the quality and efficiency of clinical care, but what happens when projects fail? What if an HIT product or project adversely affects patient safety? What can we learn from HIT failures to improve future HIT initiatives and our healthcare delivery system?

Making sense of health information technology implementation: A qualitative study protocol

BackgroundImplementing new practices, such as health information technology (HIT), is often difficult due to the disruption of the highly coordinated, interdependent processes (e.g., information exchange, communication, relationships) of providing care in hospitals. Thus, HIT implementation may occur slowly as staff members observe and make sense of unexpected disruptions in care. As a critical organizational function, sensemaking, defined as the social process of searching for answers and meaning which drive action, leads to unified understanding, learning, and effective problem solving -- strategies that studies have linked to successful change. Project teamwork is a change strategy increasingly used by hospitals that facilitates sensemaking by providing a formal mechanism for team members to share ideas, construct the meaning of events, and take next actions.MethodsIn this longitudinal case study, we aim to examine project teams' sensemaking and action as the team prepares to implement new information technology in a tiertiary care hospital. Based on management and healthcare literature on HIT implementation and project teamwork, we chose sensemaking as an alternative to traditional models for understanding organizational change and teamwork. Our methods choices are derived from this conceptual framework. Data on project team interactions will be prospectively collected through direct observation and organizational document review. Through qualitative methods, we will identify sensemaking patterns and explore variation in sensemaking across teams. Participant demographics will be used to explore variation in sensemaking patterns.DiscussionOutcomes of this research will be new knowledge about sensemaking patterns of project teams, such as: the antecedents and consequences of the ongoing, evolutionary, social process of implementing HIT; the internal and external factors that influence the project team, including team composition, team member interaction, and interaction between the project team and the larger organization; the ways in which internal and external factors influence project team processes; and the ways in which project team processes facilitate team task accomplishment. These findings will lead to new methods of implementing HIT in hospitals.

Strategies from a Nationwide Health Information Technology Implementation: The VA CART STORY

The VA Cardiovascular Assessment, Reporting, and Tracking (CART) system is a customized electronic medical record system which provides standardized report generation for cardiac catheterization procedures, serves as a national data repository, and is the centerpiece of a national quality improvement program. Like many health information technology projects, CART implementation did not proceed without some barriers and resistance. We describe the nationwide implementation of CART at the 77 VA hospitals which perform cardiac catheterizations in three phases: (1) strategic collaborations; (2) installation; and (3) adoption. Throughout implementation, success required a careful balance of technical, clinical, and organizational factors. We offer strategies developed through CART implementation which are broadly applicable to technology projects aimed at improving the quality, reliability, and efficiency of health care.

Electronic Health Records – Beyond Meaningful Use

For academic medical centers (AMCs), the past decade has seen two watershed moments in the adoption of health information technology (HIT). The first of these was the Institute of Medicine’s 2001 landmark call to action urging the widespread adoption of modern medical informatics, including electronic health records (EHRs), computerized physician order entry, and the leveraging of existing data resources [1]. And indeed, the past few years have seen significant uptake and use of HIT in the healthcare and clinical research enterprises. But while many institutions have been eager to work with these new tools, few were fully prepared to adopt these systems and only a handful were able to show measurable improvements in the quality and safety of the health care they were delivering. However, the second watershed moment – the recent emphasis on meaningful use as a key priority of HIT projects funded through American Recovery and Reinvestment Act (ARRA) grants [2] – illuminates the potential pitfalls of a simplistic approach to implementing EHRs and other aspects of HIT. It is seductively easy for healthcare institutions, including academic medical centers (AMCs), to focus on EHRs as aggregations of more or less desirable features and capabilities. However, if AMCs are to achieve the true goal of meaningful use by “...[enabling] significant and measurable improvements in population health through a transformed healthcare delivery system [3],” and even progress beyond this goal, a different perspective will be required. We at Duke have argued [4] for just such a change in perspective, one that views HIT as critical tool of patient care, research, and continuous quality improvement that must be thoughtfully integrated with carefully designed workflows and existing institutional data stores. We would further argue that for AMCs, achieving meaningful use in the context of EHRs must go beyond the basic steps of selection and adoption, where EHRs are too often viewed in terms of their functionality alone, to instead focus on measures of care delivery quality, electronic adoption, and patient engagement. For this approach to succeed, it is imperative that AMCs emphasize learning from within and applying knowledge through the thoughtful leveraging of health analytics to ensure that their EHR systems continuously evolve to become better and more integrated care delivery platforms. Success in this context will hinge upon the organization’s capacity to harness the EHR to drive a cycle of continuous learning and improvement. At Duke, we have identified five foundational aspects that we believe are critical to an AMC’s journey through and beyond meaningful use: • First, EHRs must enable and support translational research by helping to rapidly move scientific discovery from the laboratory to the patient bedside. • Second, EHRs must support patient empowerment and engagement. • Third, EHRs should help to streamline care delivery models/roles. The emphasis must be on the entire care process and not, for example, on IT silos focused on inpatient/outpatient and physician/nursing systems. • Fourth, EHRs must enable improvements in cost efficiency (clinical research and care delivery). • Fifth and finally, EHRs must enable knowledge extraction and application to the entire environment, working as a feedback mechanism to fuel the cycle of continuous quality improvement. Getting to this point will not be easy. Many U.S. AMCs still seem to view the purchase and deployment of an EHR system as sufficient in itself. Using knowledge extracted from EHRs as the foundation for building learning healthcare environments within hospitals and systems is a concept that is not well understood or even much discussed. Although some of the nation’s AMCs have advanced the idea of integrating health informatics and business analytics into the healthcare enterprise, current commercial EHR systems are not designed to support the critical capabilities outlined in the five points above. We as a nation must move past the simplistic assumptions that underlie the naive adoption of EHRs by engineering a disciplined approach to developing indicators that we can use to track and evaluate HIT in terms of its impact on patient care, research, and organizational efficiency. We stand at a critical juncture in the national effort to translate the promise of HIT into real health improvements for individuals and populations. Instead of participating in a mad dash to purchase the most popular single vendor EHR system of the moment, we should instead focus on use of clinical knowledge that could be achieved from “best of breed” multi-vendor integration of various subsystems which may already be deployed. AMCs should seize this opportunity to focus on technologies that can accommodate continuous redesign and that can be adapted to meet the changing needs of clinicians, researchers, hospital staff, patients, and communities.