Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> To achieve the goal of comprehensive health information record keeping and exchange among providers and patients, hospitals must have functioning electronic health record systems that contain patient demographics, care histories, lab results, and more. Using national survey data on US hospitals from 2011, the year federal incentives for the meaningful use of electronic health records began, we found that the share of hospitals with any electronic health record system increased from 15.1 percent in 2010 to 26.6 percent in 2011, and the share with a comprehensive system rose from 3.6 percent to 8.7 percent. The proportion able to meet our proxy criteria for meaningful use also rose; in 2011, 18.4 percent of hospitals had these functions in place in at least one unit and 11.2 percent had them across all clinical units. However, gaps in rates of adoption of at least a basic record system have increased substantially over the past four years based on hospital size, teaching status, and location. Small, nonteaching, and rural hospitals continue to adopt electronic health record systems more slowly than other types of hospitals. In sum, this is mixed news for policy makers, who should redouble their efforts among hospitals that appear to be moving slowly and ensure that policies do not further widen gaps in adoption. A more robust infrastructure for information exchange needs to be developed, and possibly a special program for the sizable minority of hospitals that have almost no health information technology at all. <s> BIB001 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> OBJECTIVE ::: In an effort to understand better the federal electronic health record (EHR) incentive programme's challenges, this study compared hospitals that did and did not receive meaningful use (MU) payments in the programme's first year based on the challenges they anticipated a year before. ::: ::: ::: MATERIALS AND METHODS ::: This cross-sectional study used 2010 American Hospital Association survey data and 2011 Centers for Medicare and Medicaid Services data that identify hospitals receiving MU payments. Multivariate regression analysis assessed differences in 2010 anticipated challenges to MU for hospitals that were successful in earning 2011 MU payment compared to hospitals that intended to participate in the programme but were not yet successful. ::: ::: ::: RESULTS ::: The study sample consisted of 2475 hospitals, 313 of which received MU payments in 2011. Controlling for standard hospital characteristics, hospitals that reported the computerized provider order entry (CPOE) MU criterion as a primary challenge were 18% less likely to receive a 2011 MU payment compared to hospitals that reported other criteria as primary challenges. ::: ::: ::: DISCUSSION ::: CPOE was the main challenge among hospitals that failed to achieve MU in the first year of the programme. In order to maximize the incentive programme's effectiveness, policymakers, healthcare organizations, and EHR vendors may benefit from increased attention to hospitals' challenges with CPOE. ::: ::: ::: CONCLUSION ::: As the EHR incentive programme matures, policymakers and other stakeholders should consider strategies that maintain the critical elements of MU while adequately supporting hospitals that desire to become MU but are impeded by specific technological, cultural, and organizational adoption and use challenges. <s> BIB002 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> Federal electronic health record (EHR)-related initiatives are leading to rapid increases in their adoption. Despite their benefits, EHRs also introduce new risks that can lead to serious safety events. We conducted a Web-based survey of the American Society for Healthcare Risk Management and the American Health Lawyers Association to elicit perceptions regarding the frequency and types of EHR-related serious safety events. We received 369 responses. The majority (66%) worked for large hospitals and health systems with varying degrees of EHR adoption. More than half (53%) of respondents reported at least one EHR-related serious safety event in the previous 5 years, and 10% reported more than 20 events. EHR workflow (63%), user familiarity with the EHR system (63%), and integration with existing systems (59%) were most frequently endorsed as variables associated with EHR-related serious safety events. Because EHR-related safety concerns are underreported, organizations should consider implementing robust measures of EHR safety within their institution as a key step for mitigating these concerns. <s> BIB003 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> Despite major national investments to support the adoption of health information technology (IT), concerns persist that barriers are inhibiting that adoption and the use of advanced health IT capabilities in rural areas in particular. Using a survey of Medicare-certified critical-access hospitals, we examined electronic health record (EHR) adoption, key EHR functionalities, telehealth, and teleradiology, as well as challenges to EHR adoption. In 2013, 89 percent of critical-access hospitals had implemented a full or partial EHR. Adoption of key EHR capabilities varied. Critical-access hospitals that had certain types of technical assistance and resources available to support health IT were more likely to have adopted health IT capabilities and less likely to report significant challenges to EHR implementation and use, compared to other hospitals in the survey. It is important to ensure that the necessary resources and support are available to critical-access hospitals, especially those that operate indepe... <s> BIB004 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> OBJECTIVES ::: The Health Information Technology for Economic and Clinical Health (HITECH) Act created incentives for adopting electronic health records (EHRs) for some healthcare organisations, but long-term care (LTC) facilities are excluded from those incentives. There are realisable benefits of EHR adoption in LTC facilities; however, there is limited research about this topic. The purpose of this systematic literature review is to identify EHR adoption factors for LTC facilities that are ineligible for the HITECH Act incentives. ::: ::: ::: SETTING ::: We conducted systematic searches of Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete via Ebson B. Stephens Company (EBSCO Host), Google Scholar and the university library search engine to collect data about EHR adoption factors in LTC facilities since 2009. ::: ::: ::: PARTICIPANTS ::: Search results were filtered by date range, full text, English language and academic journals (n=22). ::: ::: ::: INTERVENTIONS ::: Multiple members of the research team read each article to confirm applicability and study conclusions. ::: ::: ::: PRIMARY AND SECONDARY OUTCOME MEASURES ::: Researchers identified common themes across the literature: specifically facilitators and barriers to adoption of the EHR in LTC. ::: ::: ::: RESULTS ::: Results identify facilitators and barriers associated with EHR adoption in LTC facilities. The most common facilitators include access to information and error reduction. The most prevalent barriers include initial costs, user perceptions and implementation problems. ::: ::: ::: CONCLUSIONS ::: Similarities span the system selection phases and implementation process; of those, cost was the most common mentioned. These commonalities should help leaders in LTC facilities align strategic decisions to EHR adoption. This review may be useful for decision-makers attempting successful EHR adoption, policymakers trying to increase adoption rates without expanding incentives and vendors that produce EHRs. <s> BIB005 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> Over the last decade, interoperability of the Electronic Health Record (EHR) is becoming more of a reality. However, inconsistencies in documentation such as pain are considered a barrier to obtaining this goal. In order to be able to remedy this issue, it is necessary to validate reference models that have been created based upon requirements defined by Health Level 7 (HL7), Logical Names and Codes (LOINC) and the Intermountain Clinical Element Model using external published sources and guidelines. Using pain as an example of complex and inconsistent documentation, it was found that the reference model based upon these standards is valid because the data elements identified are broad and can meet the needs of each sub-domain within the primary domain of pain. <s> BIB006 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> Objective To identify implementation lessons from the United Kingdom Delivering Assisted Living Lifestyles at Scale (dallas) program—a large-scale, national technology program that aims to deliver a broad range of digital services and products to the public to promote health and well-being. ::: ::: Materials and Methods Prospective, longitudinal qualitative research study investigating implementation processes. Qualitative data collected includes semi-structured e-Health Implementation Toolkit–led interviews at baseline/mid-point ( n = 38), quarterly evaluation, quarterly technical and barrier and solutions reports, observational logs, quarterly evaluation alignment interviews with project leads, observational data collected during meetings, and ethnographic data from dallas events ( n > 200 distinct pieces of qualitative data). Data analysis was guided by Normalization Process Theory, a sociological theory that aids conceptualization of implementation issues in complex healthcare settings. ::: ::: Results Five key challenges were identified: 1) The challenge of establishing and maintaining large heterogeneous, multi-agency partnerships to deliver new models of healthcare; 2) The need for resilience in the face of barriers and set-backs including the backdrop of continually changing external environments; 3) The inherent tension between embracing innovative co-design and achieving delivery at pace and at scale ; 4) The effects of branding and marketing issues in consumer healthcare settings; and 5) The challenge of interoperability and information governance, when commercial proprietary models are dominant. ::: ::: Conclusions The magnitude and ambition of the dallas program provides a unique opportunity to investigate the macro level implementation challenges faced when designing and delivering digital health and wellness services at scale. Flexibility, adaptability, and resilience are key implementation facilitators when shifting to new digitally enabled models of care. <s> BIB007 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> Abstract Background The reuse of data captured during health care delivery is essential to satisfy the demands of clinical research and clinical decision support systems. A main barrier for the reuse is the existence of legacy formats of data and the high granularity of it when stored in an electronic health record (EHR) system. Thus, we need mechanisms to standardize, aggregate, and query data concealed in the EHRs, to allow their reuse whenever they are needed. Objective To create a data warehouse infrastructure using archetype-based technologies, standards and query languages to enable the interoperability needed for data reuse. Materials and methods The work presented makes use of best of breed archetype-based data transformation and storage technologies to create a workflow for the modeling, extraction, transformation and load of EHR proprietary data into standardized data repositories. We converted legacy data and performed patient-centered aggregations via archetype-based transformations. Later, specific purpose aggregations were performed at a query level for particular use cases. Results Laboratory test results of a population of 230,000 patients belonging to Troms and Finnmark counties in Norway requested between January 2013 and November 2014 have been standardized. Test records normalization has been performed by defining transformation and aggregation functions between the laboratory records and an archetype. These mappings were used to automatically generate open EHR compliant data. These data were loaded into an archetype-based data warehouse. Once loaded, we defined indicators linked to the data in the warehouse to monitor test activity of Salmonella and Pertussis using the archetype query language. Discussion Archetype-based standards and technologies can be used to create a data warehouse environment that enables data from EHR systems to be reused in clinical research and decision support systems. With this approach, existing EHR data becomes available in a standardized and interoperable format, thus opening a world of possibilities toward semantic or concept-based reuse, query and communication of clinical data. <s> BIB008 </s> Barriers to Electronic Health Record Adoption: a Systematic Literature Review <s> Summary of Evidence <s> BACKGROUND ::: The Health Information Technology for Economic and Clinical Health (HITECH) was a significant piece of legislation in America that served as a catalyst for the adoption of health information technology. Following implementation of the HITECH Act, Health Information Technology (HIT) experienced broad adoption of Electronic Health Records (EHR), despite skepticism exhibited by many providers for the transition to an electronic system. A thorough review of EHR adoption facilitator and barriers provides ongoing support for the continuation of EHR implementation across various health care structures, possibly leading to a reduction in associated economic expenditures. ::: ::: ::: OBJECTIVE ::: The purpose of this review is to compile a current and comprehensive list of facilitators and barriers to the adoption of the EHR in the United States. ::: ::: ::: METHODS ::: Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE, 01/01/2012-09/01/2015, core clinical/academic journals, MEDLINE full text, and evaluated only articles germane to our research objective. Team members selected a final list of articles through consensus meetings (n=31). Multiple research team members thoroughly read each article to confirm applicability and study conclusions, thereby increasing validity. ::: ::: ::: RESULTS ::: Group members identified common facilitators and barriers associated with the EHR adoption process. In total, 25 adoption facilitators were identified in the literature occurring 109 times; the majority of which were efficiency, hospital size, quality, access to data, perceived value, and ability to transfer information. A total of 23 barriers to adoption were identified in the literature, appearing 95 times; the majority of which were cost, time consuming, perception of uselessness, transition of data, facility location, and implementation issues. ::: ::: ::: CONCLUSIONS ::: The 25 facilitators and 23 barriers to the adoption of the EHR continue to reveal a preoccupation on cost, despite incentives in the HITECH Act. Limited financial backing and outdated technology were also common barriers frequently mentioned during data review. Future public policy should include incentives commensurate with those in the HITECH Act to maintain strong adoption rates. <s> BIB009
From our sample of 27 articles, we identified 68 barriers (that we collapsed into 39) that appeared in the literature a total of 125 times. Our analysis of these articles was that initial cost appeared the most often, followed by technical support, Cost of purchasing a system Productivity loss Annual maintenance cost Adequacy of training Adequacy of technical support Reliability of the system Effort needed to select a system Resistance of practice to change work habits Ability to secure financing Reaching consensus within the practice Access to high speed internet Menon S, et al. BIB003 Safety concerns 53 % of respondents claimed an EHR safety-related event in the past five years, 10 % said they experienced 20 or more in the last 5 years Errors concerned workflow processes, familiarity & training and degree of integration Gabriel MH, et al. BIB004 Cost identified several times for critical-access and rural hospitals Workflow and staffing challenges associated with maintaining an EHR. DesRoches CM, et al. BIB001 Cost Penalties (potential future barrier) Harle CA, et al. BIB002 Lack of financial incentive mentioned as Meaningful Use was meant to overcome that particular hurdle. Vest perceived usefulness, productivity loss, inability to easily input historical medical record data, eligibility criteria, technical infrastructure, physician attitude, effort needed to select system, degree of integration, facility location, ROI uncertainty, clarity of federal and state policies, physician Autonomy, consensus within the practice, penalties, user acceptance, complexity of system, limitations of system, medical errors, IMGs less likely to adopt, staff shortages, Upgrades, agility to make changes, external factors, missing data, competitiveness, provider or patient age, race and income disparities, need organizational cultural change and interoperability. Results from this systematic literature review are congruent with results from previous reviews. The most often cited barrier is cost, technical concerns, implementation, and user perceptions BIB005 BIB009  . The HITECH act began with the carrot of incentives to adopt HIT, but now it only offers the stick of reduced reimbursements for those who do not adopt HIT. As a result, few solutions to the common barriers currently exist, making policy and incentives play a crucial role in increasing the adoption rates of EHRs in the United States. Of interesting note is that of interoperability. This critical barrier only occurred in the literature once for the U.S., and only recently  . Several other articles were identified worldwide on the subject BIB006 BIB007 BIB008 . Providers have voiced their discontent with the lack of interoperability established by government agencies, which enables the static nature of EHR development at the vendor  . Providers are also frustrated by the lack of progress in interoperability because it greatly limits the progression of specialties such as pain management BIB006 . Lack of interoperability stymies efforts of information governance and information sharing between organizations BIB007 . Lastly, providers and programmers alike agree that greater interoperability is needed today to create standardization for data that can or will be staged for a data warehouse BIB008 . Policy makers should consider the results of this review when shaping additional policies and incentives for healthcare organizations in the future. This review contributes to previous findings that suggest the most common barriers revolve around cost issues, technical support, technical concerns, and resistance to change. Considering both initial and ongoing costs are ongoing barriers that may disproportionately affect certain organizations that are lagging such as practices in small and rural settings, incentives should be more directly aimed towards correcting these disparities. Policy makers should also consider ways to increase the appeal of electronic health record systems to older physicians, organizations that deal with large populations of low-income patients, and certain states that have lower adoption rates.