EHR implementations in hospitals - A systematic literature review

EHR implementations in hospitals - A systematic literature review

Arie Versluis (S1693115)

av.versluis@gmail.com

University of Groningen

Faculty of Economics and Business

MSc BA - Change Management

July 2013

Supervisor:

Prof. Dr. A. Boonstra

Second assessor:

Dr. J.F.J. Vos

1

Abstract

Background: The literature on EHR implementations in hospitals is dispersed.

Objectives: To create an overview of existing literature on EHR implementations, identifying

generally applicable findings and gaps in the literature.

Data sources: Web of Knowledge, EBSCO, The Cochrane Library, and references of

selected articles. Search terms include Electronic Health Record and synonyms, implementation, and hospital and synonyms.

Study selection: 18 articles that meet the following requirements: 1) articles written in

English, 2) full-text of articles available online, 3) articles are based on empirical studies with primary data, 4) articles focus solely on internal, hospital-wide EHR implementation.

Results: 23 general findings categorized by the framework for organizational change of

2

Introduction

Electronic Health Records (EHRs) are being implemented by an increasing number of hospitals all over the world in recent years. Take for example the initiatives, often driven by government regulations or financial stimulations, in Canada (Jaana, Ward & Bahensky, 2012), Denmark (Rigsrevisionen, 2011), and the USA (Abramson et. al., 2011). EHR implementation initiatives are driven by the promise of better patient data integration and availability (Hartswood et. al., 2003), by the need to improve efficiency and cost-effectiveness (Grimson, Grimson & Hasselbring, 2000), by a changing doctor-patient relationship towards more shared care by a team of health care professionals (Grimson et. al., 2000), and by the need to deal with a more complex and rapidly changing environment (Zack, 1999).

Implementation of hospital-wide EHR systems is a complex matter as many factors play a role, encompassing issues of objectives and values, activities, human skills, organizational structure, technical infrastructure, as well as data, financial resources and coordination (Heeks, 2006). As Grimson et al. (2000) argue, implementation of information systems (IS) in health care is even more challenging compared to other IS implementations because of the complexity of medical data, data entry problems, security and confidentiality concerns, and a general lack of awareness of the benefits of Information Technology (IT). Boonstra and Govers (2009) add three reasons of differentiation of hospitals compared to other industries, which might influence IS implementations as well. Hospitals have several objectives (curing and caring for patients, and educating new doctors and nurses), different processes than many other industries (more complicated and highly varied (Arrow, 1963)), and a diverse workforce (various professionals with their own expertise, power and autonomy (Johnson, 1972; Scott, 1982; Mintzberg, 1983; Raelin, 1991; Yi et al., 2006)).

3 To deal with the complexity of an EHR implementation in hospitals it would be helpful to know what important aspects have been identified in existing literature. That literature could help in gaining more insight in the underlying patterns and complex relations of an EHR implementation and could identify ways to deal with an EHR implementation. But no systematic review of the literature about EHR implementations in hospitals exists, therefore this article will provide one.

The purpose of this systematic literature review is to gain insight in the existing literature on the EHR implementation process in hospitals. The systematic review is focused at hospital-wide, single hospital EHR implementations and identifies the most relevant empirical articles in the field. Given the dispersed nature of the literature on EHR implementation, the scope of this review includes only the actual EHR implementation process in hospitals. By specifically focusing on the implementation process the motive for implementing an EHR system and the perceived benefits of EHR systems are decided to be out of scope. That choice is made to ensure a tight focus and prevent too much dispersion and noise. The identified articles are analyzed with regard to their research methods, their context, and their findings. The resulting overview of existing literature identifies generally applicable findings and gaps in the literature.

By performing a systematic literature review on the implementation of EHR systems in hospitals this article contributes with an overview of the existing literature on this topic to the academic field. This overview can be used as a starting point for further study on the topic of EHR implementations and provides general findings extracted from specific studies. Managers benefit from this research by taking into account-, and applying the findings and lessons to EHR implementation processes in hospitals.

4

Background

In literature several expressions are used related to electronic medical information systems, in order to ensure a good overview of literature it is important to use synonyms in the search strategy. In this article the expression Electronic Health Record (EHR) is used in the text. The most common expressions, as identified by the ISO - International Organization for Standardization (2004), are defined here and are used for this research, as well as one that is not identified by ISO. ISO (2004) considers Electronic Health Record (EHR) as the overall expression for "a repository of information regarding the health status of a subject of care, in computer processable form" (p. 13). ISO (2004) uses other terms to describe different types of EHRs. Among others the term Electronic Medical Record (EMR), which relates to the same an EHR but is restricted in scope to the medical domain. Also Electronic Patient Record (EPR) and Computerized Patient Record (CPR) are identified, both terms have the same explanation according to Häyrinen, Saranto, and Nykänen (2008): they refer to a system that contains clinical information from a particular hospital. Another term is Electronic Health Care Record (EHCR), it refers to a system that contains all health information of a patient (Häyrinen et. al., 2008) and is regarded as a synonym of EHR by ISO (2004).

An expression often used in literature is Computerized Physician Order Entry (CPOE), although not mentioned by ISO (2004) nor Häyrinen et al. (2008) it can be considered a type of EHR and is therefore used in this paper as well. Kaushal, Shojania, and Bates (2003) define Computerized Physician Order Entry as follows: "a variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders" (p. 1410).

Other expressions can also be found in literature, but they are not used for this review as they are either not relevant or too broadly defined. Such as Electronic Client Record (ECR), Personal Health Record (PHR), Digital Medical Record (DMR), Health Information Technology (HIT), and Clinical Information System (CIS).

Research questions

Based on the considerations in the introduction the following main research question is formulated:

5 Answering the main research question leads to future research directions on the topic of EHR implementations in hospitals. The selection process of existing literature includes a systematic search and selection procedure which is explained in the methodology section. Part of the selection process is a quality assessment of the articles using the standard quality assessment criteria as identified by Kmet, Lee and Cook (2004). After the selection process the selected articles are characterized with regard to the country of data collection, the methods used, the participants, the focus of the article as well as their theoretical background and approach. Next to that the findings with regard to EHR implementation in hospitals are categorized and synthesized using the framework for strategic change of Pettigrew (1987). The findings from the articles are generalized, creating an overview of general findings. The importance of generalization for scientific research, as well as the needed caution in generalizing specific findings is well explained by Mayring (2007). From the general findings gaps in literature are identified. These gaps serve as input for future research directions on EHR implementations in hospitals.

Conceptual model

The categorization of the findings from the selected articles draws on Pettigrew's framework for understanding strategic change (Pettigrew, 1987). It consists of three related dimensions, being context, content, and process of an organizational change, and is a general framework for analyzing organizational change. As implementation of an EHR system is an organization-wide effort the framework of Pettigrew (1987) is applicable. Specifically this framework is selected for its focus on change, its ease of understanding, and its relatively general dimensions allowing for a broad range of findings to be covered. It structures and focuses the analysis of the findings from the selected articles.

6 does not see strategic change as a rational analytical process, but merely as an iterative, continuous, multilevel process. This highlights that the outcome of an organizational change is the result of these three dimensions, and most importantly of the interaction between the three dimensions.

Six categories are extracted from the model, three of which are related to the three dimensions, and three of which are related to the interaction between these dimensions. The framework with the identified categories, as shown in figure 1, serves as the conceptual model for categorizing the findings of this systematic literature review. As explained in the introduction the systematic review is focused at hospital-wide, single hospital EHR implementations. The scope is limited to the actual EHR implementation process in hospitals to ensure a tight focus and prevent too much dispersion and noise.

Figure 1: Conceptual model consisting of the framework of Pettigrew (1987) and the corresponding finding categories.

Methodology

In order for this systematic literature review to be a comprehensive research it is important to make sure that all expressions in the research question are addressed in the search. Besides that, relevant synonyms or related expressions should be used as well, both for electronic medical information systems and hospitals. For implementation no often used synonym is identified, however, conjugations might be used in literature like 'implement' or 'implementing'. By using an * at the end of a term the search engines search for conjugations

7 as well and by adding " " around the words it is ensured that the total expression is searched for, by using a ? instead of a character every possible character is searched for. These considerations lead to the following terms for hospitals: hospital*, "health care", and clinic*. As mentioned no other often used synonym for implementation is identified, the search item implement* is therefore the only used one. For electronic medical information systems the following names are searched for: "Electronic Health Record*", "Electronic Patient Record*", "Electronic Medical Record*", "Computeri?ed Patient Record*", "Electronic Health Care Record*", "Computeri?ed Physician Order Entry".

Databases

The following three search engines are chosen based on their relevance to the field and their availability to the researcher. Most search engines use several databases but not all of them are relevant for this research as they serve completely different fields. Those that are not even slightly relevant are excluded from the search, see Appendix A for an overview of the databases.

 Web of Knowledge (5 databases, all used)  EBSCO (37 databases, 11 used)

 The Cochrane Library (7 databases, all used)

Search Strategies

The relatively large set of keywords is necessary to ensure that no articles are missed in the search, as a result a lot of search strategies are needed to use those keywords. It is important to find papers about the implementation of an electronic medical information system in

hospitals, so the search strategies consist of three terms. The following search strategies can

be used in all three databases in the same manner. However some search options are slightly different in order to reduce the noise in the results. Therefore, in search engines the second and third term is searched in titles only.

8 In EBSCO, next to excluding irrelevant databases (appendix 1), no specific search field is selected for the first term, Title is used for the second and third term, and the option to search in scholarly (peer reviewed) journals is used.

In The Cochrane Library the search field 'Title, Abstract, Keywords' is used for the first term and Record Title for the second and third term, with no other limitations to the search.

Search strategy 1: "Electronic Health Record*" + implement* + hospital* Search strategy 2: "Electronic Health Record*" + implement* + "health care" Search strategy 3: "Electronic Health Record*" + implement* + clinic* Search strategy 4: "Electronic Patient Record*" + implement* + hospital* Search strategy 5: "Electronic Patient Record*" + implement* + "health care" Search strategy 6: "Electronic Patient Record*" + implement* + clinic* Search strategy 7: "Electronic Medical Record*" + implement* + hospital* Search strategy 8: "Electronic Medical Record*" + implement* + "health care" Search strategy 9: "Electronic Medical Record*" + implement* + clinic* Search strategy 10: "Computeri?ed Patient Record*" + implement* + hospital* Search strategy 11: "Computeri?ed Patient Record*" + implement* + "health care" Search strategy 12: "Computeri?ed Patient Record*" + implement* + clinic* Search strategy 13: "Electronic Health Care Record*" + implement* + hospital* Search strategy 14: "Electronic Health Care Record*" + implement* + "health care" Search strategy 15: "Electronic Health Care Record*" + implement* + clinic*

Search strategy 16: "Computeri?ed Physician Order Entry" + implement* + hospital* Search strategy 17: "Computeri?ed Physician Order Entry" + implement* + "health care" Search strategy 18: "Computeri?ed Physician Order Entry" + implement* + clinic*

The references of the articles that meet the selection criteria are checked for possible other relevant studies not identified with the database search.

Selection Criteria

9

Results

Search results

Applying the 18 search strategies on the different search engines resulted in a total of 364 articles. The searches have been done on the 12th of March 2013 for search strategies 1-15 and on the 18th of April 2013 for search strategies 16-18. The latter strategies are added based on a preliminary analysis of the first search results, which showed several other names and descriptions of information technology in health care. In the resulting 364 articles a lot of duplicates were found both by the same search engine and by different search engines. By removing duplicates the first found article was kept, as Web of Knowledge was the first used search engine most remaining articles came from this search engine. The one article found in The Cochrane Library was a duplicate of an earlier found article. 160 duplicates were found using the Refworks functions for identifying exact and close duplicates, however it identified not all duplicates. Therefore a manual check by the author was done to remove an additional number of 23 duplicates.

The remaining 181 articles have been screened on title and abstract with regard to the selection criteria. In case of an unclear title and abstract the content of the paper has been consulted. This screening has resulted in 13 articles that met all selection criteria. By checking the references of these articles another 8 articles have been identified. Of the resulting 21 articles 2 proved to be almost the same, showing only slight differences in text and layout, and being published in different journals. As the authors for both articles are the same no suspicion of plagiarism is needed. Nevertheless one article was excluded, resulting in 20 articles left before quality assessment.

10 final amount of 18 articles remain for in-depth analyses. The process from article search to final article selection is graphically displayed in a flow chart (figure 2).

With respect to the quality assessment it is striking that most authors of qualitative studies did not use verification procedures on the data to establish credibility of the study nor showed any reflexivity on the impact of their personal characteristics and methods used.

Figure 2: Flow chart of article selection process.

Overview of included articles

To gain more insight in the context and nature of the 18 remaining articles an overview is given in table 4. All studies except one are published in the 21st century, which can be explained by the increased use of information technology in society, the rising attention to implementing organization wide information systems like EHR systems and the increasing

Web of Knowledge: 194 potentially

relevant articles

EBSCO: 169 potentially

relevant articles

The Cochrane Library: 1 potentially relevant article Total of 364 potentially relevant articles 183 duplicates excluded

Total of 181 articles for

screening

Total of 13 articles for

further assessment

164 excluded

based on selection criteria

Total of 21 articles

meet selection criteria

12

Table 1: Overview of included studies in the systematic literature review

Art icle nr. Aut ho r & pu bli ca tio n y ea r Co un try / re g io n M a in o bje ct iv e o f st ud y T y pe o f re sea rc h Da ta co llect io n P a rt icipa nts (s a mp le size, re spo ns e ra te) H o spita l ty pe Imp a ct fa ct o r* C it a tio ns * * [1] (Aarts, Doorewa ard & Berg, 2004) The Netherlands

To examine the three theoretical aspects (social process, emergent change, socially negotiated judgments) to understand the implementation process. Qualitative Semi-structured interviews, observations, document analysis

10 members of the project team from different disciplines

Teaching hospital 4.329 194 [2] (Aarts & Berg, 2006) The Netherlands

To understand the outcomes of CPOE

implementation using a heuristic model and to identify factors that determine successful implementation. Qualitative Open interviews, observations, document analysis

25 interviews with project team members, physicians, nurses, technical and clerical personnel

Teaching hospital & regional hospital 1.090 47 [3] (Ash et al., 2001) USA/ Virginia, Washington, California

To find out how some hospitals had successfully implemented POE. Quantitative and Qualitative Survey, semi-structured interviews, focus groups, observations Quantitative: 1000 hospitals (37% response rate)

Qualitative: 32 interviews with physicians, nurses, pharmacists, IT-staff, administrators quantitative : 1000 hospitals qualitative : 2 teaching hospitals, 2 community hospitals - 37 [4] (Ash et al., 2003) USA/ Virginia, Washington, California

To describe perceptions ofPOE held by diverse

professionals at both teaching and nonteaching sites where POE has been successfully

implemented. Qualitative Semi-structured interviews, focus groups, observations

Clinicians, administrators, and information technology personnel 2 teaching hospitals, 2 community hospitals 4.329 160 [5] (Boyer et al., 2010)

France To examine health care professionals’ opinions on

the critical events (opportunitiesand barriers)

surrounding EMR implementation

Qualitative

Semi-structured interviews

115 psychiatrists, nurses, psychologists and social assistants, secretaries and administrative professionals Psychiatric teaching hospital 0.420 0 [6] (Ford et al., 2010)

USA To assess complete versusincomplete HIT

implementation levelsamong U.S. hospitals in

light of thevarious technology adoption strategies

employed and to discuss the implicationswith

respect to meaningful use forhospitals that have

adopted the differentHIT strategies.

Quantitative Survey 1,814 hospitals All kinds of

hospitals

13 [7] (Houser & Johnson, 2008) USA/Alaba ma

1. To determine the status of implementation of EHRs in hospitals in the state of Alabama; 2. To assess the factors that are driving the decision making for implementation of EHRs; and

3. To assess the perceptions of HIM professionals of the benefits, barriers, and risks that are associated with implementation of EHRs.

Quantitative Survey 131 directors in health

information management, 69% response rate Members of the Alabama Hospital Association - 19 [8] (Jaana, Ward, & Bahensk y, 2012)

USA/Iowa To present an overview of clinical information

systems (IS) in hospitalsand to analyze the level

of electronic medical records (EMR)

implementation inrelation to clinical IS

capabilities and organizational characteristics.

Quantitative Survey 116 CEOs or CIOs, 84% response

rate Nonfederal hospitals - 3 [9] (Katsma et al., 2007) The Netherlands

To contribute to the developments in method engineering which promises a better participation of the user.

Qualitative Interviews 12 people, being supported

sponsor, process owner or key-user

4 hospitals - 4

[10] (Ovretvei

t et al., 2007)

Sweden To describe and assess an implementation in one

hospital and analyze this in relation to factors

suggestedby previous research to be important

for successfulimplementation as well as in

relation to a published USA casestudy, which

used similar methods.

Qualitative Interviews 30 persons, project leaders,

supervisors, heads of division and clinics, instructor, nurses, doctors, and doctor secretary

Teaching hospital

2.480 86

[11] (Poon et

al., 2004)

USA To provide more insight into the challenges to

CPOE implementation.

Qualitative Interviews 52 CIOs/CFOs/CMOs and senior

managers from 26 hospitals (46 hospitals were contacted: 57% response rate Both teaching and non-teaching hospitals 3.748 269 [12] (Rivard, Lapointe, & Kappos, 2011)

Canada To propose a substantive theory – a theory

developed for a particulararea of inquiry (Gregor,

2006) – to provide an organizational

culture-based explanation of the level ofdifficulty of a

CIS implementation and of the implementation

practices that can help reduce the levelof

difficulty of this process.

Qualitative Interviews 43 people, physicians, nurses, and

administrators 3 hospitals, 2 teaching and 1 community hospital 2.654 9 [13] (Scott et al., 2005)

USA/Hawaii To examine users’ attitudes toimplementation of

an electronic medical recordsystem in Kaiser

Permanente Hawaii.

Qualitative Interviews 26 senior clinicians, managers and

project team members

One hospital, 4 clinics 13.51 1 174 [14] (Takian, Sheikh, &Barber, 2012)

England To report on a case study of the implementation

of an EHR (RiO) into a mental health setting delivered though the NPfIT and analyzed using

our adapted ‘sociotechnicalchanging framework’.

Qualitative Interviews,

observations, document analysis

48 interviews with senior managers, implementation team members, healthcare practitioners

Mental health hospital

14

[15] (Ward et

al., 2011)

USA To examine the impact of clinical information

system implementation on nurses’ perceptions of

workflowand patient care throughout the

implementationprocess.

Quantitative Survey 705 nurses Rural hospital - 3

[16] (Ward et

al, 2012)

USA To examine staff perceptions of patient care

quality and the processes before and after implementation of a comprehensive clinical information system (CIS) in critical access hospitals (CAHs).

Quantitative Survey 840 nurses, providers, and other

clinical staff Critical access hospitals 2.540 0 [17] (Weir et al., 1994)

USA/Utah To identify factors that discriminatesuccessful

from non successful implementation ofOE/RR

2.5 in order to prepare for the next version.

Quantitative Survey 52 medical administration staff,

administrators, support staff, users (ward clerks, physicians, and nurses), and physician opinion leaders (92 received survey, thus 57% response rate) 6 hospitals - 29 [18] (Yoon-Flannery et al., 2008) USA/New York

To determine pre-implementation perspectives of institutional, practice and vendor leadership regarding best practice for implementation of two

ambulatory electronic health records (EHRs)at an

academic institution.

Qualitative Interviews 31 interviews with institutional

leaders, practice leaders and vendor leaders.

Teaching hospital

- 25

15

Articles' perspectives

In research it is common to use theoretical frameworks for designing a study on an academic level (Van Aken, Berends, & Van der Bij, 2012). Theoretical frameworks provide a way of thinking about and looking at the subject matter and describe the underlying assumptions about the nature of the subject matter (Botha, 1989). By building on existing theories a research is focused and will aim to enrich and extent the existing knowledge in that particular field (Botha, 1989). To create a more thorough understanding of the selected articles their theoretical frameworks, if present, are outlined in table 2.

Table 2: Overview of theoretical frameworks of included studies

Article nr.

Author &

publication year Theoretical framework

[1] (Aarts et al., 2004) Three theoretical aspects: 1) sociotechnical approach, 2) emergent change

with an unpredictable outcome, and 3) "success" and "failure" are socially negotiated judgments and is determined by the fit between work processes and information technology.

[2] (Aarts & Berg,

2006)

A model on success or failure of information systems with four variables: (1) information system, (2) support base, (3) medical work practices, and (4) hospital organization. Successful implementation of an information system (1) is defined as the capability to create a support base (2) for the change of (medical) work practices (3) induced by the system (4).

[3] (Ash et al., 2001) None

[4] (Ash et al., 2003) None

[5] (Boyer et al., 2010) None

[6] (Ford et al., 2010) HIT adoption strategies: (1) Single-vendor strategy, (2) Best of Breed

strategy, and (3) Best of Suite strategy.

[7] (Houser & Johnson,

2008)

None

[8] (Jaana et al., 2012) None

[9] (Katsma et al.,

2007)

IT implementation success is determined by quality (relevance) times acceptation (participation). Relevance is defined as the degree to which the user expects that the IT system will solve his problems or help to realize his actually relevant goals. Participation of employees is perceived to increase their acceptation of the IT system. Effectiveness of participation is moderated by organizational receptiveness, individual ego development, and knowledge availability.

[10] (Ovretveit et al.,

2007)

None

[11] (Poon et al., 2004) None

[12] (Rivard et al., 2011) A culture-based explanation of the level of difficulty of a CIS implementation,

using an integration perspective (basic assumptions are shared among the members of the collective), a differentiation perspective (subgroups within a collective have inconsistent interpretations), and a fragmentation perspective (members within a collective sometimes manifest multiple interpretations, irrespective their subgroup).

[13] (Scott et al., 2005) None

[14] (Takian et al.,

2012)

A sociotechnical framework as identified by Aarts et al. (2004), underscoring the emerging nature of change.

[15] (Ward et al., 2011) None

[16] (Ward et al, 2012) None

[17] (Weir et al., 1994) None

[18] (Yoon-Flannery et

al., 2008)

16 It is striking that 12 of the 18 selected articles do not use a specific theoretical framework to base their research on. Most articles just come with an objective to gain insight in certain aspects regarding EHR implementation (as identified in table 1) and use a non-focused grounded theory approach to identify and categorize their findings. These articles add knowledge to the field of EHR implementations but do not attempt to extend existing theories. A change to integrate knowledge and to create homogeneity in the field is missed.

Aarts et al. (2004) introduce the notion of the sociotechnical approach, emphasizing the importance of focusing both on the social aspects of an EHR implementation and the technical aspects of the system. With the concept of emergent change they argue that an implementation process is far from linear and predictable, due to contingencies and organizational complexity influencing the process. These two concepts are referred to by Takian et al. (2012) as their theoretical framework as well. The last concept of Aarts et al. (2004) is more or less an elaboration of their sociotechnical approach in which the level of fit between work processes and information technology determines the success of the implementation.

Aarts and Berg (2006) elaborate on the last aspect of their aforementioned article (Aarts et al., 2004) and introduce a model on success or failure of information systems implementations. Creating synergy between the medical work practices and the information system as well as the hospital organization is necessary for successful implementation and will only happen if enough people accept a change of work practices. Katsma et al. (2007) focus on implementation success as well, thereby stating that quality (relevance) times acceptation (participation) determines success. Relevance relates to the perceived benefits of the user and participation to the involvement of users in the implementation process. Katsma et al. (2007) thus take a more social view on implementation success compared to the sociotechnical approach.

Rivard et al. (2011) research the difficulty of a CIS implementation from a cultural perspective. They not only view culture as a set of assumptions shared by the whole collective (integration perspective), but expect subcultures to exist (differentiation perspective), as well as individual assumptions not shared by a specific (sub) group (fragmentation perspective).

17 The articles of Aarts et al. (2004), Aarts and Berg (2006), and Takian et al. (2012) more or less use the same sociotechnical framework as a lens for their research. Katsma et al. (2007) have a more social framework by focusing on relevance of an IT system as perceived by the user and the participation of users in the implementation process. Rivard et al. (2011) also focus on the social side of IT implementation by analyzing culture from three different perspectives. Ford et al. (2010) look at adoption strategies which leads them to focus on the selection procedure of HIT. The twelve other articles use no theoretical framework to build on and to focus their research.

Findings

Extracting all findings from the 18 included articles resulted in a total of 174 findings, which can be found in Appendix C. Since the aim of this article is to analyze these findings and extract general findings on the implementation of EHR systems in hospitals, a categorization of these general findings seemed wise to increase clarity. The earlier introduced conceptual model, based on Pettigrew's framework for understanding strategic change, shows six categories, being context (A), content (B), process (C), and the interaction categories consisting of content interaction (D), content-process interaction (E), and context-process interaction (F). As this review is specifically aiming to identify findings related to the implementation process, reasons for-, barriers to-, and outcomes of EHR implementation are out of scope.

18 tables show, the larger number of general findings could be extracted from the three dimensions (16) compared to the three interaction variables (7).

Category A - Context. The context category of the EHR implementation process, consists of

both internal variables (like resources, capabilities, culture, and politics) and external variables (like economic, political, and social variables). Six general findings have been identified, which are all but one related to internal variables. An overview of the findings and corresponding articles can be found in table 3. The lack of external findings can be explained by the fact that reasons like political or social pressure to implement an EHR system are out of the scope of this review. Also internal findings like perceived financial benefits or improved quality of care fall out of the defined scope.

Table 3: Category A - Context findings

General finding Finding

code

Article numbers

Larger (or system-affiliated), urban, not-for-profit, and teaching hospitals are more likely to have implemented an EHR system, due to more financial capabilities, higher change readiness, and less focus on making profit.

A1 6/7/8/10

Successful EHR implementation requires selecting a mature vendor who is committed to providing a system that fits specific hospital's needs.

A2 10/11

Previous experience of hospital staff with Health Information Technology increases the likelihood of successful EHR implementation, as less uncertainty is experienced by end users.

A3 7/10/14/15/17

An organizational culture supporting collaboration and teamwork fosters EHR implementation success, because trust between employees is higher.

A4 3/4/5/13

Successful EHR implementation is more likely in an organization with little bureaucracy and more flexibility, as changes can be made faster.

A5 5/17

A1: Larger (or system-affiliated), urban, not-for-profit, and teaching hospitals are more likely to have implemented an EHR system, due to more financial capabilities, higher change readiness, and less focus on making profit. Research shows that larger or

19 a more wait-and-see approach of private hospitals and a more progressive, change ready nature of public and teaching hospitals (Ovretveit et al., 2007; Ford et al., 2010).

A2: Successful EHR implementation requires selecting a mature vendor who is committed to providing a system that fits specific hospital's needs. This finding will not be

surprising, nevertheless it is wise to elaborate on it a bit. By having a hospital selecting its own vendor it can be ensured that it will fit specific needs of that hospital (Ovretveit et al., 2007). Next to that it is important to do business with a vendor that has proven itself on the EHR market with mature, successful products (Poon et al., 2004). With that in mind the initial price of the system should not be the main consideration, as costs exceed the initial price when problems arise.

A3: Previous experience of hospital staff with Health Information Technology increases the likelihood of successful EHR implementation, as less uncertainty is experienced by end users. In order to be able to work with an EHR system users must be

capable of using information technology like computers and be able to type sufficiently (Ovretveit et al., 2007; Weir et al., 1994). Knowledge of, and previous experience with, EHR systems or other medical information systems reduces uncertainty and disturbance for users, which results in a more positive attitude towards the system (Houser & Johnson, 2008; Ovretveit et al., 2007; Takian, Sheikh & Barber, 2012; Ward et al., 2011).

A4: An organizational culture supporting collaboration and teamwork fosters EHR implementation success, because trust between employees is higher. The influence of

organizational culture on organizational change success is addressed in almost all popular change management approaches, as well as in several articles subject of this literature review. Ash et al. (2001, 2003) and Scott et al. (2005) highlight a strong culture with a history of collaboration and teamwork and trust between different stakeholder groups, minimizing resistance to change. Boyer et al. (2010) suggest to create a favorable culture that is more change ready, such a culture will foster EHR implementation success (Ovretveit et al., 2007). Creating a favorable culture is not as easy as it sounds, a comprehensive approach including incentives, resource allocation, and a responsible team was used in the example of Boyer et al. (2010).

A5: Successful EHR implementation is more likely in an organization with little bureaucracy and more flexibility, as changes can be made faster. Bureaucracy hampers

20 created to prevent conflict and stimulate collaboration (Boyer et al., 2010). Communication is more direct and problems can be solved right away.

Category B - Content. The content of the EHR implementation process consists of the EHR

system and corresponding objectives, assumptions, and complementary services. Table 4 lists the four extracted general findings, focusing on both the hardware and software of the EHR system, and its relation to work practices and privacy.

Table 4: Category B - Content findings

General finding Finding

code

Article numbers

Adapting both technology and work practices to create fit is a key factor for successful implementation of EHR systems.

B1 1/9/14/17

To ensure usage of the EHR, hardware availability and system reliability with regard to speed, availability, and lack of failures are a necessity.

B2 4/5/7/10/14/17/18

To ensure usage of the EHR, software needs to be user-friendly with regard to ease of use, efficiency in use, and available functionality.

B3 4/10/17

An EHR implementation should contain adequate safeguards for patient's privacy.

B4 5/7/14/18

B1: Adapting both technology and work practices to create fit is a key factor for successful implementation of information systems. This finding elaborates on the

sociotechnical approach identified in the section about the theories of the articles (Aarts et al., 2004; Katsma et al., 2007; Takian et al., 2012). The authors make clear that creating a fit between the EHR system and the existing work practices first requires the acknowledgement that an EHR implementation is not just a technical project and that existing work practices will change due to a new system. By adapting the system to specific needs, users will be open to use it (Weir et al., 1994).

B2: To ensure usage of the EHR, hardware availability and system reliability with regard to speed, availability, and lack of failures are a necessity. A lot of articles mention

21

B3: To ensure usage of the EHR, software needs to be user-friendly with regard to ease of use, efficiency in use, and available functionality. Some authors distinguish between

technical availability and reliability and user-friendliness of the software (Ash et al., 2003; Ovretveit et al, 2007; Weir et al., 1994). They argue that it is not enough for a system to be available and reliable, it should be easy and efficient to use, and provide the functionality required for medical staff to give good care. If a system fails to do so they will not use the system and stick to the old way of working.

B4: An EHR implementation should contain adequate safeguards for patient privacy. The concern of privacy is recognized by Boyer et al. (2010) and Houser and Johnson

(2008) as a barrier to EHR implementation. Others (Takian et al., 2012; Yoon-Flannery et al., 2008) recognize the importance of patient privacy as well but instead of viewing it as a barrier they emphasize addressing the issue by providing training and creating adequate safeguards.

Category C - Process. This is the actual process of implementing the EHR system. Variables

are time, change approach, and change management. This category owns the most findings (table 5), as might be expected due to the focus of this review on the implementation process.

Table 5: Category C - Process findings

General finding Finding

code

Article numbers

Due to their influential position, active involvement and support of management is positively associated with EHR implementation success.

C1 4/5/10/13/17

Participation of clinical staff in the implementation process increases support and acceptance of the EHR implementation.

C2 5/10/13/17

Training of end-users is important for EHR implementation success. C3 7/10/17

A good, comprehensive implementation strategy is needed for

implementing an EHR system, offering both clear guidance and room for emergent change.

C4 1/5/9/17/18

A facilitating factor associated with successful implementation of an EHR system is mandatory implementation, so leaving no choice for alternative ways of working.

C5 17

A Best of Suite adoption strategy is associated with more successful EHR implementation success compared to a Best of Breed and a Single Vendor adoption strategy.

C6 6

An interdisciplinary implementation group consisting of developers, members of the IT department, and end users fosters EHR implementation success.

C7 10/17

C1: Due to their influential position, active involvement and support of management is positively associated with EHR implementation success. Several authors mention the

22 mention supportive leadership (Ash et al., 2003; Weir et al., 1994), others more firmly state that strong and active leadership is needed (Boyer et al., 2010; Ovretveit et al., 2007; Scott et al., 2005). Scott et al. (2005) also distinguish styles of leadership in different phases, for selection decisions participatory leadership is valued, for the actual implementation a more hierarchical leadership style is prefered.

C2: Participation of clinical staff in the implementation process increases support and acceptance of the EHR implementation. Participation of end users (the clinical staff)

increases acceptance and allows problems to be solved quick (Boyer et al., 2010). Clinical staff should participate at all levels and in all steps (Ovretveit et al. 2007; Weir et al., 1994), from the initial system selection on (Scott et al, 2005).

C3: Training of end-users is important for EHR implementation success. End-users

of the new EHR system are generally not experienced with the EHR system or EHR systems at all. Although society or workplaces without IT is hard to imagine nowadays a large, specific system like an EHR requires training to use it properly. The importance of training is often underestimated, but inadequate training will create a barrier to successful EHR usage (Houser & Johnson, 2008; Weir et al., 1994). Therefore, adequate training at the right times must be provided (Ovretveit et al., 2007; Weir et al., 1994).

C4: A good, comprehensive implementation strategy is needed for implementing an EHR system, offering both clear guidance and room for emergent change. Several articles

highlight aspects of an implementation strategy for EHR systems. A good strategy is facilitating successful EHR implementation (Boyer et al., 2010; Weir et al., 1994), and consists of careful planning, a sustainable business plan, and effective communication (Yoon-Flannery et al., 2008). Emergent change is perceived to be a key characteristic of an EHR implementation in a complex organization like a hospital (Aarts et al., 2004) and is in line with a development paradigm implementation approach (Katsma et al., 2007). The notion of emergent change has been made in, among others, both theoretical frameworks of the articles of Aarts et al. (2004) and Katsma et al. (2007).

C5: A facilitating factor associated with successful implementation of an EHR system is mandatory implementation, so leaving no choice for alternative ways of working.

23 between clinicians and support staff. Their results show that only clinicians who were part of a successful implementation mentioned the importance of mandatory implementation. As the next category shows the clinicians are an influential group in hospitals and it is therefore interesting to keep this finding in mind.

C6: A Best of Suite adoption strategy is associated with more successful EHR implementation success compared to a Best of Breed and a Single Vendor adoption strategy. As already mentioned in the examination of the theoretical frameworks of the

articles Ford et al. (2010) research a distinct topic, the type of adoption strategy used for EHR implementation. Their research shows that the Best of Suite adoption strategy is most often related to fully implemented HIT systems. Ford et al. (2010) suggest that this strategy reduces the need for disruptive redesigns and thus also reduces resistance.

C7: An interdisciplinary implementation group consisting of developers, members of the IT department, and end users fosters EHR implementation success. In line with the

arguments for management support and for participation of clinical staff Ovretveit et al. (2007) and Weir et al. (1994) build their case for using an interdisciplinary implementation group. By having all direct stakeholders work together a better EHR system can be delivered faster and with less problems.

Category D - Context-Content interaction. The interplay between contextual variables and

the content of the EHR implementation consists of two general findings related to physicians and vendors respectively (table 6).

Table 6: Context-Content interaction findings

General finding Finding

code

Article numbers

Physician resistance is a major barrier to EHR implementation, but can be reduced by addressing their concerns.

D1 2/4/7/10/11/13

Successful EHR implementations requires a vendor who is willing to adapt its product to hospital work processes.

D2 10/11

D1: Physician resistance is a major barrier to EHR implementation, but can be reduced by addressing their concerns. As mentioned in the explanation of finding C5 the

24 (Aarts & Berg, 2006). The likelihood of acceptance will be increased if the concerns of physicians are addressed by the implementers (Ash et al., 2003; Ovretveit et al., 2007; Poon et al., 2004).

D2: Successful EHR implementations requires a vendor who is willing to adapt its product to hospital work processes. A vendor must be willing to adapt its product to ensure a

good and usable EHR system (Poon et al., 2004). By doing so the dependence on the vendor decreases and concerns from within the hospital can be addressed (Ovretveit et al., 2007). This finding is related to D1 in the sense that a cooperative and flexible vendor is needed to deal with all forces in a hospital, like for example the physicians.

Category E - Content-Process interaction. The interplay between the content of the EHR

implementation and the process of implementing the EHR is represented by only one general finding (table 7).

Table 7: Content-Process interaction findings

General finding Finding

code

Article numbers

EHR system implementation is difficult because good care must be ensured at all times.

E1 12/16

E1: EHR system implementation is difficult because good care must be ensured at all times. During the process of implementing an EHR system, it is of the utmost importance

to ensure good care at all times, since this is the primary process of hospitals (Rivard et al., 2011; Ward et al., 2012). Ensuring such good care while implementing an EHR increases the difficulty of an EHR implementation and is an important distinct factor compared to general IT implementations.

Category F - Context-Process interaction. The interplay between the context of the EHR

implementation and the process of implementing the EHR is covered in several articles and has resulted in four general findings (table 8).

Table 8: Context-Process interaction findings

General finding Finding

code

Article numbers

Identifying physician champions is important in EHR implementations for reducing resistance among physicians.

F1 10/11

Assigning a sufficient number of personnel to the process of implementing the EHR is important to adequately implement the system.

25

To effectively deal with the relatively high level of physicians' medical dominance strong leadership is needed.

F3 11/12

Successful EHR implementation needs an understanding of the

unpredictability of the implementation process, caused by contingencies that are not expected nor planned for.

F4 1/14

F1: Identifying physician champions is important in EHR implementations for reducing resistance among physicians. Finding D1 already elaborated on physician resistance and

suggests to reduce that by addressing physician's concerns. Another way to reduce their resistance is related to the process of implementation. By identifying physician champions, typically well-respected clinicians, resistance is reduced due to their knowledge and contacts (Ovretveit et al., 2007; Poon et al., 2004).

F2: Assigning a sufficient number of personnel to the process of implementing the EHR is important to adequately implement the system. Implementing a large EHR system

requires a lot of resources, of which human resources is one. By assigning a sufficient number of personnel to that process the chances of success will be heightened (Poon et al., 2004; Weir et al., 1994). This also interesting in relation with finding E1, concerning the pursuit of the primary process of providing health care in a time of organizational change.

F3: To effectively deal with the relatively high level of physicians' medical dominance strong leadership is needed. Rivard et al. (2011) point out that physicians'

medical dominance and other health professionals' status and autonomy hinders collaboration and teamwork which complicates EHR implementation. Poon et al. (2004) acknowledge that point of view and argue for strong leadership to deal with the relatively dominant physicians.

F4: Successful EHR implementation needs an understanding of the unpredictability of the implementation process, caused by contingencies that are not expected nor planned for. In light of their emphasis on emergent change with unpredictable outcomes Aarts et al.

(2004) make their case for acknowledging the fact that unexpected and unplanned contingencies influence the implementation process. They argue that the resultant changes of these contingencies often manifest themselves in hindsight and must be dealt with. As an addition to that Takian et al. (2012) state that it is crucial to contextualize the EHR implementation in order to be able to anticipate.

26 interactions between two of the dimensions. The identification and explanation of these general findings ends the results section of the systematic literature review and forms the basis of the discussion.

Discussion

The review of the existing academic literature sheds light on the current knowledge about EHR implementations. The 18 selected articles originate from North America or Europe, which might be explained by the two following factors: the greater governmental attention to EHR implementations in Western countries and the sole selection of articles written in English. All articles but one are published in the 21st century, as can be explained by the increasing attention for implementing EHR systems in hospitals. Six articles use a theoretical framework to build their research on, three of which generally use the same lens of the sociotechnical approach (Aarts et al., 2004; Aarts & Berg, 2006; Takian et al., 2012). Katsma et al. (2007) and Rivard et al. (2011) focus more on the social aspects of an EHR implementation, the first on relevance for-, and participation of users, the latter on three different perspectives of culture. Ford et al. (2010) research adoption strategies of EHR systems. It is notable that the other articles use no theoretical framework to analyze EHR implementation and attempt not to elaborate on existing theories.

A total of 174 findings are extracted from the articles, those findings are categorized using the framework for strategic change of Pettigrew (1987) as a conceptual model. The conceptual model consists of the three dimensions context, content and process, and of three categories related to the interaction between each two of the dimensions. The scope of the review is limited to findings related to the EHR implementation process, leaving out the reasons for-, barriers to-, and outcomes of an EHR implementation, to ensure a tight focus. About one third of the findings therefore is regarded out of scope, of the remaining findings 23 general findings are extracted.

27 (Boyer et al., 2010; Poon et al., 2004; Scott et al., 2005; Ward et al., 2011), others mention an increase instead (Houser & Johnson, 2008; Katsma et al., 2007). Finding A2 is a good reminder to carefully select a vendor, taking into account its experience on the EHR market and the maturity of their products, rather than for example the cost price of the system. Because of the huge investment costs the price of an EHR tends to have a high influence on the vendor selection, which is also promoted by the current European tendering regulations that oblige (semi-)public institutions, like much hospitals, to choose for the lowest bidder or the bidder that is economically most preferable (Bergman & Lundberg, 2013). The importance of addressing the concern of privacy (B4) can be exemplified with the termination of the Dutch attempt to introduce a nationwide EHR system in 2010 due to privacy concerns (Rijksoverheid, 2013).

The process of implementation, category C, shows four findings that are commonly mentioned in change management approaches as important success factors for organizational change. Active involvement and support of management (C1), participation of clinical staff (C2), a good, comprehensive implementation strategy (C4), and using an interdisciplinary implementation group (C7) corresponds for example with three of the ten commandments Kanter et al. (1992) gave to us. Those three commandments are: (1) support a strong leader role, (2) communicate, involve people and be honest, and (3) craft an implementation plan. As the implementation of an EHR system is an organizational change process it is no surprise that these commonalities are identified and confirmed in several different analyzed articles. The finding that mandatory implementation is a facilitating factor for successful EHR implementation (C5) was only mentioned in one article. Nevertheless, it is worthwhile addressing it. On the one hand it seems logical to oblige staff to use such a large, expensive, influential system, on the other hand research shows that sometimes hospital staff refused to use the EHR system and remained working in the familiar way. In these instances it led to a halt or termination of the EHR system implementation (Aarts & Berg, 2006).

28 attention as well. On this subject an EHR system implementation distinguishes itself from general IT implementations, as human lives are at stake in hospitals. That distinction not only complicates the implementation process, during which medical work practices have to continue, but also requires a flawless system from the moment it is launched.

Now that the findings have been interpreted individually it is important to interpret the results of the review in general. What stands out is that most findings (16) are related to one specific dimension of the EHR implementation process, respectively context (5), content (4) and process (7). Only seven findings relate to one of the interaction categories, of which four are placed in the context-process interaction category. That leaves context-content interaction with two findings and content-process interaction with just one finding. These outcomes might be due to the type of research, most articles that are part of this review are merely case analyses of-, or surveys about EHR implementations and described facilitating factors or barriers. Little attention is paid to assessing the EHR implementation process as an integrated process of multiple interacting variables.

Analyzing and comparing the findings leads to the insight that a categorization on subject can be made (table 9). By categorizing the findings on subject and adding the number of different articles related to the findings on that subject it is easily deductable how much attention different subjects get in literature. Organizational structure is the subject with the least attention with only two articles addressing it, the vendor is slightly more often addressed with three articles making notice of it.

Table 9: Findings sorted by subject

Subject Related findings Nr. of articles

Involvement in the process C1, C2, C7, F2 6

Vendor A2, C6, D2 3

Implementation strategy C4, C5, F4 6

Physicians' role D1, F1, F3 7

Users' skills/experience A3, C3 5

EHR system B2, B3 7

Patient issues B4, E1 6

Hospital demographics A1 4

Organizational culture A4 4

Organizational structure A5 2

Fit between work processes and EHR system B1 4

29 The above discussion of the results clarifies the existing knowledge on EHR implementation and reveals knowledge gaps.

Future research directions

Based on the gaps identified in the discussion the following future research directions might be taken:

 Future research could focus on aspects that are kept out of the scope of this article, like reasons for-, or barriers to-, and outcomes of EHR implementations in hospitals.  A direction for future research could also be a more in depth investigation to the

reasons for private hospitals not to implement an EHR.

 Another future research direction could be on efficiency of work practices after an EHR implementation, current literature is dispersed about that topic. That research could aim to identify reasons for a decrease in efficiency and come up with solutions to increase the efficiency of work practices with an EHR system.

 Investigating the influence of the European tendering regulations on EHR adoption would also be of interest, in light of the focus on lowest prices instead of on quality.  The notion of mandatory implementation is interesting and deserves further research.  Future research could focus on analyzing interaction variables in EHR

implementation. This analysis, using the framework of Pettigrew (1987) has shown that little attention is paid on such interaction variables.

 More attention in research could be paid to the organizational structure of a hospital and to identifying what structure is favorable for successful EHR implementation.  The role of the vendor and its impact on the EHR implementation could be

investigated more in depth in future research.

 Future research could use one or several of the identified articles on a specific subject to build on and extend their views. The current literature on EHR implementations is dispersed and not well integrated.

 Future research could develop a comprehensive approach to EHR implementations in hospitals, based on the existing literature. Such an approach is currently missing in the literature.

Research limitations

30 excluded articles that used different wordings in the titles. Searching the reference lists of identified articles found several of such articles, but some relevant articles might be missed. Another limitation in the search is the exclusion of languages other than English. Selection and categorization of the specific findings and extraction of the general findings is subject to the interpretation of the author, one might have made different choices. Interpreting the findings and extracting future research directions are also conclusions based on individual analysis. All findings are perceived as equally important in this research, whereas dissimilarity between findings existed within articles.

Conclusion

The number of EHR implementations in hospitals is growing, as well as the body of literature on the subject matter. This systematic literature review has addressed the existing literature and as a result 23 general findings on EHR implementation, divided over six categories, are identified. A number of general findings is in accordance with existing literature on change management, other findings relate to the specific nature of EHR implementations in hospitals.

The findings of this article give an overview of important subjects that need to be addressed in order to successfully implement EHR systems. It is clear that EHR implementation comes with its own complexities and should be executed with great care and attention to context, content, and process issues and their interaction. The discussion of the findings revealed knowledge gaps that are translated to future research directions. Thereby the research question is answered and the systematic review of the existing literature on EHR implementation is created.

The academic contribution is the now available overview of existing literature with regard to important aspects of EHR implementations in hospitals. Academics interested in this specific field can easily obtain knowledge on EHR implementations in hospitals and can use this article as a starting point to study the existing literature. On top of that, several suggestions for future research are given, guiding scholars in further extending the knowledge of the EHR implementation field.

31 Knowledge and application of these points will increase the likelihood of a successful EHR implementation.

32

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