Table Of ContentBarriers for Adopting Electronic Health Records (EHRs) by Physicians 129
acta inform med. 2013 jun; 21(2): 129-134 doi: 10.5455/aim.2013.21.129-134
Received: 15 January 2013 • Accepted: 26 March 2013
conflict of interest: none declared
© AVICENA 2013
Barriers for Adopting Electronic Health Records
(EHRs) by Physicians
sima ajami, tayyebe Bagheri-tadi
department of Health information technology, Health management & economics research center, school of
medical management and information sciences, isfahan university of medical sciences, isfahan, iran
corresponding author: tayyebe Bagheri-tadi. school of medical management and information sciences, isfahan university of medical
sciences, isfahan, iran. e-mail: [email protected].
professional paper must actively use these systems to accrue the cal record, electronic health record, barrier,
aBstract benefits. This study was unsystematic-review. and adoption in the searching areas of title,
introduction: Electronic Medical Records aim: The aim of this study was to express bar- keywords, abstract, and full text. In this study,
(EMRs) are computerized medical informa- riers perceived y physicians to the adoption of more than 100 articles and reports were col-
tion systems that collect, store and display the EHRs. method of the study: This study was lected and 27 of them were selected based
patient information. They are means to create non-systematic reviewed which the literature on their relevancy. Electronic health record
legible and organized recordings and to access was searched on barriers perceived by physi- use requires the presence of certain user and
clinical information about individual patients. cians to the adoption of Electronic Health system attributes, support from others, and
Despite of the positive effects of the EMRs Records (EHRs) with the help of library, books, numerous organizational and environment
usage in medical practices, the adoption rate conference proceedings, data bank, and also facilitators.
of such systems is still low and meets resis- searches engines available at Google, Google key words: physicians; electronic health re-
tance from physicians. The EHRs represent an scholar. discussion: For our searches, we cord; barrier; adoption
essential tool for improving both in the safety employed the following keywords and their
and quality of health care, though physicians combinations: physicians, electronic medi-
1. introduction
Electronic Medical Records of electronic health records. Never-
The Institute of Medicine reported (EMRs) are computerized medical in- theless, there is evidence suggesting
to Err is Human that building a Safer formation systems that collect, store that these systems have not been ad-
Health System cites one of the most and display patient information. opted. Physicians have a central role
extensive adverse drug event studies, They are means to create legible and in the use of the EHRs, as they are
the Harvard Medical Practice Study, organized recordings and to access who provide much of the informa-
and notes that 58 percent of adverse clinical information about individual tion that the systems handle in their
events due to errors in the study were patients. The EMRs and Electronic automated processes (4).
preventable, 27.6 percent were due to Health Records (EHRs) are viewed Despite broad agreement on the
negligence, and 19 percent were due as interchangeable synonyms in most benefits of electronic health records
to drug complications which were the health informatics. Other similar ex- and other forms of health informa-
most common adverse event. In order pressions exist albeit with a some- tion technology, health care pro-
to: 1) reduce medical errors, 2) pro- times slightly restricted focus (2). viders have moved so slowly to adopt
vide more effective methods of com- The Institute of Medicine and these technologies. Lack of readiness
municating and sharing informa- others have suggested that the wide- causes weakness of organization to
tion among clinicians, and 3) better scale adoption of the EHRs could be undergo transformation during the
manage patient medical records, we pivotal for improving patient safety implementation of the EHRs (5). Ac-
need to embrace information tech- and health care quality. EHRs may cording to Meinert, the slow rate of
nology in healthcare. Since medical also reduce the costs of providing adoption suggests that resistance
errors are a leading cause of death in ambulatory care. However, despite among physicians must be strong be-
the United States and since paper re- emerging evidence about the benefits cause physicians are the main front-
cords can be easily lost, misplaced, or of EHRs, there are considerable bar- line user-group of EMRs. Whether or
are often illegible, the use of electronic riers to adoption (3). not they support and use EMRs will
health record technology would elim- The health care sector is an area have a great influence on other user-
inate many of these issues and lead of social and economic interest in groups in a medical practice, such as
to major improvements in the health several countries; therefore, there nurses and administrative staff. As a
and safety of patient care (1). have been lots of efforts in the use result, physicians have a great impact
aCTa inFOrM MeD. 2013 Jun; 21(2): 129-134 / prOFeSSiOnal paper
130 Barriers for Adopting Electronic Health Records (EHRs) by Physicians
on the overall adoption level of EMRs Title Author Expected or experienced barriers
(6). What factors affect the use of Lack of time;
electronic patient records Meade B et al. (10) Lack of financial resources;
Mille and Sim stated that based on
by Irish GPs? Absence of computer skills;
a qualitative study of physician prac- Results of a survey of an online High cost;
tices that had implemented an EMR, physician community regarding use of Ross (11) Loss of autonomy;
the EMRs in office practices. Workflow disruption.
quality improvement depends heavily
Start-up financial costs;
on physicians’ use of the EMR and Correlates of EHRs Adoption in office Simon et al. (3) ongoing financial costs;
Practices: A Statewide Survey
not paper for most of their daily tasks Loss of productivity.
(7). The adoption and meaningful use Doctors’ use of the EMRs systems in Access to computers and computer literacy;
Lærum et al. (12) flexibility of paper records;
of electronic health records (EHRs) is hospitals: cross sectional survey Traditional work routines.
a major US national policy priority User attitude towards;
for improving the quality and effi- A knowledge-based taxonomy of information systems
critical factors for adopting EHR Workflow impact;
ciency of the healthcare system. This systems by Castillo et al. (4) Interoperability;
topic has received bipartisan support physicians: a systematic literature Technical support;
review Communication among users;
and led to the US Congress allocating
Expert support.
close to $30 billion in 2009 to pro- Data entry;
mote adoption of interoperable, cer- If the EMRs are so great, Less confidence in the
Loomis et al. (13) security and confidentiality;
tified the EHRs (8). Why family physicians don’t use them? Concern about the cost for installation and ongoing
According to Randeree, as tech- usage of EMRs.
nology continues its impact in Training and after-sales experience with the vendor;
Technical support from the vendor;
healthcare, the adoption of new IT Primary Care Physicians’ Experience Extra time needed for data entry;
with
options has been able to reduce costs Ludwick et al. (14) Time constraint in procurement and
EMRs: Barriers to Implementation in
Implementation;
and increase efficiencies. Health care a fee-for-Service Environment
Computer skills of the physicians;
professionals now turn to various pa- Disruption of the flow of information.
tient-centric technologies, including Malfunction;
Use of EMRs in oman and Physician
farsi (15) Concern about privacy;
computerized patient records (CPR), Satisfaction
Cost.
document management systems, An organizational learning perspective Investment cost;
data warehouses, point-of-care appli- on the assimilation of the EMRs among Reardon et al. (16) Productivity loss;
small physician practices Lack of financial incentives.
cations, distributed networks, and
System downtime;
telematics (Telematics typically is Increase in physician workload;
any integrated use of telecommunica- Providers have inadequate computer skills;
Increase in staff workload;
tions and informatics, also known as
Staff have inadequate computer skills;
ICT (Information and Communica- Patient confidentiality;
Expense of implementation;
tions Technology), to provide the in- Adoption of EHRs in Primary Care
Kemper et al. (17) Lack of clear return on investment;
formation they need when they need Pediatric Practices No improvement in patient care or clinical outcomes;
it (9). Interference with doctor-patient relationship;
Inability to find an EHRs that meets the pediatric
Simon et al. argued that physi- practice’s requirements;
cians who had adopted an EHR con- Inability to interface with existing practice systems;
Transience of vendors 70.1;
sistently reported more positive views
Bad previous experience with EHRs.
of the potential effect of computers Capital needed to acquire and implement;
on health care than physicians who Uncertainty about return on investment;
Resistance to adoption from practice physicians;
did not yet (3).
Capacity to select, contract and install the EHR;
Miscommunication, misinforma- Concern about loss of productivity during transition;
EHRs in small physician practices: Concern about inappropriate disclosure of patient
tion and misinterpretation between
Availability, use, and perceived Rao et al. (7) information;
vendors, clinic executives, IS leaders, benefits. Concern about illegal record tampering/hacking;
and end-users (physicians and staff) Concern about the legality of accepting the EHR from
a hospital;
has contributed to a myriad of prob- Concern about physician’s legal liability
lems in the marketing, selection, im- finding an EHR that meets your needs;
Concern that the system will become obsolete;
plementation and utilization of the
Computer skills of you and/or colleagues/
EMRs (5).
staff;
The aim of this study was, to iden-
Computer technical support;
tify and discuss about barriers for
Lack of time to acquire knowledge about
adopting Electronic Health Records EHRs: Use, barriers and satisfaction system;
(EHRs) by physicians. among physicians who care for black Jha et al. (18) Start-up financial costs;
and Hispanic patients
ongoing financial costs
2. metHods
Training and productivity loss;
This study was un-systematic re- Physician skepticism;
view which the literature on physi- Privacy or security concerns;
cians’ resistance in adoption of Elec-
tronic Health Records on a formal re-
prOFeSSiOnal paper / aCTa inFOrM MeD. 2013 Jun; 21(2): 129-134
Barriers for Adopting Electronic Health Records (EHRs) by Physicians 131
search framework. We used a sub-sys- 1) Cost;
2) Increase in staff workload;
tematic method, which was divided
Exploring Physician Adoption of EMRs: 2) Supplier presence;
Randeree (8)
into three phases: literature collec- A Multi-Case Analysis 3) Vendor trust;
tion, assessing, and selection. The lit- 4) Customizability;
5) Reliability.
erature search was conducted The lit-
Costs;
erature was searched on barriers per- Quality of health care;
Physicians and EHRs
ceived by physicians to the adoption A Statewide Survey Simon et al. (19) Interactions with the health care team;
Patient-physician communication;
of the EHRs with the help of library, Patient privacy
books, conference proceedings, data Privacy;
bank, and also searches engines avail- Patient safety;
Adopting EMRs primary care: Provider/patient relations;
able at Google, Google scholar. For Lessons learned from health Staff anxiety;
our searches, we employed the fol- information systems Ludwick et al. (20) Time factors ;
implementation experience in seven Quality of care;
lowing keywords and their combina-
countries finances;
tions: Physicians, electronic medical Efficiency;
Liability.
record, electronic health record, bar-
Physicians In Non-primary Care And Practice size;
rier, adoption in the searching areas
Small Practices And Those Age 55 And Decker et al. (21) Physician age;
of title, abstract and full text. older Lag In Adopting EHR Systems ownership status;
More than 100 articles were col- High initial financial costs;
Slow and uncertain financial payoffs;
lected. After exclude duplicated arti-
High initial physician time costs;
cles, some articles were excluded base Physicians’ Use of EMRs: Barriers And Difficulties with technology;
Miller et al. (6)
Solutions Complementary changes and support;
on the following criteria: 1) article
Electronic data exchange;
related to barriers linked to physi- financial incentives.
cians no to other medical staff, 2) ar-
Uncertainty about implementation costs, causes and
ticle focused on EHR, not involving Resistance Is futile: But It Is Slowing
effects;
the Pace of EHR Adoption Nonetheless ford et al. (22)
other electronic systems. After fil- Uncertainty about shifting standards;
tering 27 articles were selected. We Uncertainty about potential policy interventions.
Learning curve;
investigated all of them to identified
Impact on productivity;
barriers to the acceptance of EHRs Response time;
Cost;
by physicians. Then we studied how Resistance to EMRs:
Meinert (5) Security;
these barriers affect on physicians’ re- A Barrier to Improved Quality of Care Patient acceptance;
sistance using EHR. Finally we pro- Privacy;
Complexity;
posed some useful interventions that Training needs.
can act as references for implementers Learning;
of Electronic Health Records. Typing proficiency;
Understanding the EHR system;
Motivation/initiative;
3. results Strategies/workarounds;
Supporting hardware/software system ;
All of the barriers that have men-
Speed;
What Stands in the Way of
tioned in the 20 articles have showed functionality;
Technology-Mediated Patient Safety
Usability;
in the following Table 1. Improvements? A Study of facilitators Holden (23)
formal technical support;
Information is enough valuable and Barriers to Physicians’ Use of formal training;
EHRs
and it must be well documented, Informal support from colleagues;
Time allowance;
maintained, retrieved and analyzed. Inter-institutional integration;
In health management systems, in- Physical space;
Electricity;
formation has a special role in plan-
Wireless connectivity;
ning, evaluation, training, legal as- Social environment.
pects and research (24). In fact, the
first distinction between developed Table 1. Some experienced barriers to Adopt EHRs by physicians
and developing countries, are the
production, application and utiliza- Taking extra time to use EHR and using external vendors to provide the
tion of information (25, 26, 27). not being compensated for taking a services. These costs may include pur-
Some articles had similar barriers. lighter load were perceived barriers. chase price, coordination costs, mon-
Most barriers were mentioned in ar- Physicians reported that they needed itoring costs, and negotiating costs,
ticles are discussed below: but did not always have time to use upgrade costs, and governance costs.
3.1. Time the system fully, to participate in fur- These costs act contrary to the ben-
Physicians do not take the time to ther training, or to learn new features efits provided by the EMR. For small
properly become familiar with the (22). to medium sized practices without
available products, select an EMR, 3.2. Cost large IT budgets, costs remain the
implement it, and then train to use it Physicians have to weigh the costs biggest barrier to adoption (8). The
even though colleagues have invested of creating and supporting their own high up-front financial costs of im-
time and realized great benefit (13). IT structure and applications, or plementing EMRs are a primary bar-
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132 Barriers for Adopting Electronic Health Records (EHRs) by Physicians
rier to their adoption. This barrier is works to help innovation users pro- available sometimes (off hours; holi-
compounded by uncertainty over the mote social interaction, which assists days) (22).
size of any financial benefits that may them to adopt innovations (4). 3.13 Interoperability
accrue over time (6). 3.7. Interfaces with doctor-pa- Interoperability as a determinant
3.3. Absence of computer skill tient relationship factor for adopting these systems that
The skills needed to listen to pa- A few researchers have considered interoperability could reduce rework
tients’ complaints, assess medical rel- the possibility of interaction prob- by care providers; improve dissemina-
evance, contemplate interventions as lems between doctors and patients tion and movement of new medical
well as type notes all at the same time when using EMRs. Patient eye contact knowledge among physicians. In-
would require a significant level of is and, therefore, the more complete teroperability is important because it
concentration, typing skills, and fa- the interpersonal communication, decreases the cost of electronic health
miliarity with the application’s user possibly leading to higher quality of records and makes it feasible for an
interface, not normally found in the care. In the research by Ludwick et al. individual or small group of physi-
most adept computer users (13). some physicians reported that they cians to acquire and adopt these sys-
EMR providers appear to under- sometimes stop using EMRs because tems (4).
estimate the level of computer skills hunting for menus and buttons dis- 3.14. Access to computers and
required from physicians, while the rupts the clinical encounter (13). computer literacy
system is not only seen as but in prac- 3.8. Lack of incentives The low level of electronic med-
tice actually is very complex to use The EMRs use could be increased ical records system use could be ex-
by these physicians. Further, good through financial rewards for quality plained by a lack of available com-
typing skills are needed to enter pa- improvement and for public re- puters. This would, however, affect
tient medical information, notes and porting of multiple measures of the use for all clinical tasks in a uni-
prescriptions into the EMRs, and quality performance (6). form manner (11).
some physicians lack them (2). 3.9. Complexity 3.15. Vendor trust
3.4. Workflow disruption The multidisciplinary of screens, Lack of technical training and sup-
Physicians do not take the time to options, and navigational aid Prob- port from vendors has been reported
properly become familiar with the lems with EMR usability especially as a barrier to the adoption of EMRs
available products, select an EMR, for documenting progress notes by physicians. Therefore, the quality
implement it, and then train to use it caused physicians to spend extra of vendors of EMR systems is crucial
even though colleagues have invested work time to learn effective ways to for the acceptance of EMRs. EMR
time and realized great benefit. The use the EMR. These substantial ini- systems are still relatively new in the
skills needed to listen to patients’ tial time costs are an important bar- marketplace. The lack of suitable ven-
complaints, assess medical relevance, rier to obtaining benefits, as greater dors reflects an immature industry,
contemplate interventions as well as burdens on physicians’ time decrease without sufficient viable products
type notes all at the same time would their use of EMRs, which lowers the or competitors able to offer better
require a significant level of concen- potential for achieving quality im- services, and without enough infor-
tration, typing skills, and familiarity provement (6). mation on vendors to enable an in-
with the application’s user interface, 3.10. Physical space formed decision. Physicians are con-
not normally found in the most Barriers included cluttered work- cerned that vendors are not qualified
adept computer users (4). spaces, insufficient space for a paper to provide a proper service, or will go
3.5. Concern about security and chart when using EHR, not enough out of business and disappear from
privacy private rooms for computer use, com- the market, leading to a lack of tech-
Despite of evidence to the con- puter stations ill-suited to tall users, nical support and a large financial
trary, nonusers believe that there are and physicians not being physically loss (2).
more security and confidentiality located at a computer station (e.g., 3.16. Expert support
risks involved with EMRs than paper when commuting (22). Expert support refers to the assis-
records (12). There is added concern 3.11. Concern about the ability tance provided from a physician to
for privacy, confidentiality, and secu- to select an effectively install HER another physician. This can be di-
rity for computerized patient infor- system vided in two aspects: 1) a physician
mation (14). Physicians were far more worried with experience in electronic health
3.6. Communication among users about finding a system that met their records usage assists, with informa-
Communication among users needs or the future obsolescence of tion about how to use the system, to
refers to the act of interchanging their EHR systems (7). another physician; 2) a physician has
thoughts, opinions, or information 3.12. Technical support the knowledge to help another physi-
by speech, or writing. Communica- Technical support facilitated use cian accomplish a medical task. Such
tion among users is as a very impor- both in the initial days and weeks of assistance can be given through per-
tant factor contributing to the user EHR and afterward. Support staff was sonal contact or via documents (4).
acceptance of these systems. The generally perceived as knowledgeable 3.17. Concern about data entry
communication among users might and helpful, although some physi- Practicing family medicine re-
be encouraged through social net- cians noted that support staff was un- quires varied skills, a fast pace,
prOFeSSiOnal paper / aCTa inFOrM MeD. 2013 Jun; 21(2): 129-134
Barriers for Adopting Electronic Health Records (EHRs) by Physicians 133
treating patients from multiple age Physicians would spend more time nicians to easily and effectively use
groups, diagnosing conditions from a interacting with the computer than the EHR. That, in turn, will increase
myriad of potentially unrelated com- the patient. In these cases it was clear the probability of quality and safety
plaints, and keeping a comprehensive that the respondents did not view the improvements through the EHR. The
record from multiple sources. These EMR as an opportunity to enhance review showed that implementers
factors make data entry the largest or improve physician-patient commu- can insulate the project from such
potential obstacle to the effective use nication (5). concerns by establishing strong lead-
of computers in family medicine (4). 3.22. Formal training ership, using project management
3.18. Training and after-sail ex- Although initial formal training techniques, establishing standards
periences with their vendor was depicted favorably by some, in- and training their staff to ensure such
Our physicians complained about sufficient training was often identi- risks do not compromise implemen-
their training and post-sale experi- fied as a barrier, either because there tation success. Many medical schools
ence with their vendor. Instead of a was not enough training or because do not employ the EHRs or train stu-
training regimen similar to that de- classroom training was ill-suited dents in their use. Training medical
scribed in the literature, physicians to physicians’ clinical needs and students to rely upon EHRs and their
reported that their vendor simply of- learning styles (22). decision support tools can only serve
fered one training session of one half 3.23. Speed to accelerate universal the EHR adop-
to a full day in duration. Training System slowness in some units, but tion. The findings of this study can be
was often too soon after implemen- not in others, was perceived as a bar- used as an overview of barriers that
tation. Physicians had not developed rier to use (22). physicians might possibly see in the
sufficient experience with their new 3.24. Interinstitutional integra- EMR implementation process.
EMR to ask relevant questions or ap- tion
references
preciate the answers. Physicians re- Physicians could not use patient
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