Barriers to the Acceptance of Electronic Medical Records by Physicians

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MASTER’S THESIS

Barriers to the Acceptance of

Electronic Medical Records by Physicians

From Meta-analysis to Taxonomy and Interventions

29

th

_{of August, 2009}

Yuqin Lu Author

S1741764

Wagnersingel 12A, 9722 CX Groningen, The Netherlands S1741764@student.rug.nl

Prof. A. Boonstra Research Supervisor

Faculty of Economics and Business Landleven 5, 9747 AD

Groningen, The Netherlands albert.boonstra@rug.nl

Dr. H. Broekhuis

Second Research Supervisor

Faculty of Economics and Business Landleven 5, 9747 AD

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Y Lu Barriers to the Acceptance of Electronic Medical Records by Physicians

Master’s Thesis 2

Abstract

Purpose: The major goal of this research is to identify and categorize every possible barrier and resistance

from physicians towards the adoption of Electronic Medical Records (EMRs). Furthermore, barrier-related interventions from the perspective of change management will be introduced.

Methods: A systematic literature review, based on articles from 1998 to 2009, concerning the barriers of

acceptance of EMRs by physicians, was conducted. Four databases, “Science”, “EBSCO”, “PubMed” and “The Cochrane Library”, were used for the search of literature.

Results: This study includes twenty articles, based on barriers towards EMR from physicians. Eight main

categories of barriers, consisting of in total thirty-one sub-categories, were identified. These eight categories are: A) Financial, B) Technical, C) Time, D) Psychological, E) Social, F) Legal, G) Organizational and H) Change Process. All categories of these barriers are interrelated with each other. Especially, Category G (Organizational) and Category H (Change Process) are mediating factors of other barriers.

Additionally, the presence and relative importance of barriers were measured with the use of a barrier matrix, containing four quadrants: “Important Barriers”, “Unimportant Barriers”, “Unimportant Non-barriers” and “Important Non-Non-barriers”. As a result of this measurement, “Financial” and “Time” barriers were detected as “Important Barriers”, “Technical” and “Social” barriers as “Unimportant Barriers” and “Psychological” and “Legal” as “Unimportant Non-barriers”.

Finally, focusing on the perspective of change management, the author uses the Three-Step Model of Planned Change to derive eight barrier-related interventions to overcome the mentioned barriers as much as possible.

Conclusion: The process of EMR implementation should be treated as a change project, led by

implementers or change managers in medical practices. The quality of change management plays an important role in the success of EMR implementation. The findings and suggested interventions of this study are only meant as a reference for the implementers and change mangers. These parties should apply specific and relevant interventions only after a careful self-diagnosis of their particular situation.

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Y Lu Barriers to the Acceptance of Electronic Medical Records by Physicians Master’s Thesis 3

I. Introduction ... 5 II. Methods ... 7 1. Search Strategy ... 7 2. Selection Criteria ... 8 3. Data Analysis ... 8 III. Results ... 9 1. Included Studies ... 9 2. Taxonomy of Barriers ... 14 (1) Category A: Financial ... 14 (2) Category B: Technical ... 15 (3) Category C: Time ... 18 (4) Category D: Psychological ... 20 (5) Category E: Social ... 21 (6) Category F: Legal ... 22 (7) Category G: Organizational ... 23

(8) Category H: Change Process ... 24

IV. Analysis ... 27

1. Relationship among the Barriers ... 27

2. Measuring the presence and importance of the barriers ... 28

3. Change Approach ... 30

4. Interventions ... 31

V. Discussion ... 37

VI. Conclusion ... 39

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Master’s Thesis 4

List of Tables and Figures

Table 1: Overview of Included Studies ……….10

Table 2: Taxonomy of Barriers……….26

Table 3: Interventions and Related Barriers………..…31

Figure 1: Flow chart of study………9

Figure 2: Relationship among the barriers………..27

Figure 3: Barrier Matrix……….28

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Master’s Thesis 5

I. Introduction

Electronic Medical Records (EMRs) are computerized medical information systems that collect, store and display patient information. They provide a method to create legible and organized recordings and to obtain clinical information about individual patients.

Furthermore, EMRs aim at replacing paper medical records which are already familiar to the practitioners (McLane, 2005). Patient records have been stored in paper form over centuries and, within this period of time, they consumed space and notably delayed access to efficient medical care (Da’ve, 2004). In contrast, EMRs electronically store individual patient clinical information and make an instant availability of this information possible.

A widely used synonym of Electronic Medical Records (EMRs) is “Electronic Health Records” (EHRs), which is interchangeable with EMRs in most health informatics. Also other commonly spread synonyms of Electronic Medical Records (EMRs) exist, which are actually different types of EMRs. EMRs have a general focus on medical care, while Electronic Patient Records (EPRs) and Computerized Patient Records (CPRs) “contain clinical information about a patient from a particular hospital” and Electronic Health Care Records (EHCRs) “contain a patient’s health information” (Häyrinen et al., 2008, p.295). Advantages of EMRs can be summarized as “optimizing the documentation of patient encounters, improving communication of information to physicians, improving access to patient medical information, reduction of errors, optimizing billing and improving reimbursement for services, forming a data repository for research and quality improvement, and reduction of paper” (Yamamoto & Khan, 2006, pp.184-185). As EMRs have great potential for improving quality, safety and efficiency in healthcare, they are implemented all over the world.

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Master’s Thesis 6 the “main users” of EMRs: physicians, medical specialists and general practitioners. It will not pay attention to barriers of other user-groups like nurses, administrative staff or IT personnel. Furthermore, identifying important barriers of introducing EMRs may help the implementers to intervene more focused and to successfully implement this system.

In the research field of EMR adoption, few researchers regard the implementation of EMR as a change project performed in medical practices. Thus, this paper has a new and different perspective, the perspective of change management, to examine problems of slow EMR adoption and then to suggest relative interventions of overcoming its barriers. What should be learnt from this research is that the quality and appropriateness of change management will have a great influence on the success of EMR implementation - mostly neglected by other researchers. The purpose of this paper is to give an overview of the barriers toward EMRs by physicians, to find out the relationship among these barriers and to identify the important ones. Moreover, this research will offer relevant change-management interventions to overcome the barriers in the process of EMR implementation. Implementers and change managers, who are implementing or intend to implement EMRs in medical practices, will have a gain from reading this piece of research.

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Master’s Thesis 7

II. Methods

1. Search Strategy

In order to keep this study recent, up-to-date and comprehensive, a systematic literature search on four relevant databases (“Web of Science”, “EBSCO”, “PubMed” and “The Cochrane Library”) was conducted, covering the period from January 1998 to May 2009. The search was performed by using the key words “barrier*”, “physician*”, “electronic medical record*”, “electronic health record*”, “adopt*” and the combinations of them in an appropriate way. The reference lists of included studies were scanned for further relevant articles.

On the database “Web of Science”, the search was carried out according to the following search strategies:

Search Strategy 1: Key words (in the field of “Topic”): barrier* + Electronic Medical Record* Search Strategy 2: Key words (in the field of “Topic”): barrier* + Electronic Health Record* Search Strategy 3: Key words (in the field of “Topic”): physician* + Electronic Medical Record* Search Strategy 4: Key words (in the field of “Topic”): physician* + Electronic Health Record*

For “Search Strategy 3” and “Search Strategy 4”, results of the search in “Subject Areas” and “Document Types” were further refined in order to enhance their relevance. The “Subject Areas” results were limited to its sub-parts “Health Care Sciences & Services”, “Medical Informatics”, “Medicine”, “General & Internal”. “Document Types” results were refined as “Article” and “Proceeding Paper”.

On EBSCO, the search was based on the following two strategies:

Search Strategy 5: Key words (in the field of “TI Title”): barrier* + Electronic Medical Record* Search Strategy 6: Key words (in the field of “TI Title”): barrier* + Electronic Health Record*

On “PubMed”, 3 search strategies for the initial collection of the literature were performed:

Search Strategy 7: Key words (in the field of “Title”): barrier* + Electronic Medical Record* Search Strategy 8: Key words (in the field of “Title”): barrier* + Electronic Health Record*

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Master’s Thesis 8 On “The Cochrane Library”, the following strategies were used:

Search Strategy 10: Key words (in the field of “Title, Abstract or Keywords”): barrier* + Electronic

Medical Record*

Search Strategy 11: Key words (in the field of “Title, Abstract or Keywords”): physician* + Electronic

Medical Record*

Search Strategy 12: Key words (in the field of “Title, Abstract or Keywords”): physician* + Electronic

Health Record*

2. Selection Criteria

All studies included in the literature review met the following selection criteria: 1) articles electronically accessible as full texts; 2) articles written in English; 3) article solely focused on EMR or EHR and no other electronic systems used in medical practices; 4) articles related to barriers of physicians (medical specialists, general practitioners), not to other medical staff; 5) empirical articles from scientific journals. Therefore, those articles not specifically focusing on EMR / EHR (e.g. IT system, computerization, etc.) were excluded. Besides, articles, whose target groups were practices or clinicians, were not assessed, because these articles not only included physicians, but also nurses, physician’s assistants and other staff. When more than one article presented the same data, the relevance of the articles was reviewed first. If all of these articles were relevant, only the most recent one was selected. The articles in the reference lists were also assessed according to the above mentioned criteria.

3. Data Analysis

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Master’s Thesis 9

III. Results

1. Included Studies

By searching the databases “Web of Science”, “EBSCO”, “PubMed” and “The Cochrane Library” under 12 search strategies, 1,671 articles were identified (including duplicate articles from different databases) (See Figure 1). After the initial screening, 446 articles were excluded, because 372 of them were not electronically available in full text and 74 were duplicates. Among 1225 full-text articles, 1179 were excluded because they did not meet the criteria 2), 3) and 4), based on the content of their titles and abstracts. Of 46 articles in the further assessment, 25 articles were only commentaries or literature reviews, therefore not empirical and had to be excluded. Of 21 empirical studies, 2 of them were presenting the same data for the same analysis. Thus, only 1 of these 2 articles was included. No extra articles were obtained from the reference lists, as those meeting the selection criteria were included before. Finally, 20 articles met the inclusion criteria. In the following Table 1 shows the selected articles:

Figure 1 Flow chart of study selection

Source: Author’s own figure.

Web of Science: 908 potentially relevant articles EBSCO: 26 potentially relevant articles PubMed: 651 potentially relevant articles

The Cochrane Library: 86 potentially relevant

articles

1671 articles retrieved for initial screening

46 relevant articles for further assessment

1179 excluded, based on

title and abstract

21 empirical articles

25 excluded, based on study

design

20 included studies

1 excluded, because of

presentation of the same data

446 excluded based on

inaccessibility in full text (n=372) or duplicate (n=74)

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Table 1 Overview of Included Studies Article No. First Author Year Country of Data Collection Clinical

Area Expected Barriers or Experienced Barriers

Type of Research (Qualitative/ Quantitative) If qualitative If quantitative Focus Number of Cases Number of Physicians Involved Methods for Data Collection Sample size Methods for Data Collection

1 Jha et al. 2009 U.S.A All specialties

1) computer skills of physicians and/or staff 2) computer technical support 3) lack of time to acquire knowledge about

system

4) start-up financial costs 5) ongoing financial costs

6) training and productivity loss 7) physician skepticism

8) privacy or security concerns

Quantitative 1132 Questionnaire All barriers 2 DesRoches et al. 2008 U.S.A Direct patient care 1) capital costs 2) not finding a system that met their needs

3) uncertainty about their return on the

investment 4) concern that a system would become obsolete

Quantitative 2758 survey All barriers

3 Menachemi

et al. 2007 U.S.A

Ambulatory care

1) upfront cost of hardware/software 2) ongoing maintenance costs 3) inadequate return on investment

4) extra time for data entry 5) lack of time to acquire & implement such a

system

6) slow the physicians down 7) temporary loss of productivity and/or revenue 8) no time to learn how to use 9) disrupts workflow and/or office's physical

layout 10) lack of uniform data standards within the

industry 11) temporary loss of access to patient records if

computer crashes or power fails 12) products do not meet the needs

13) the physicians and/or the staff don't have any

technical knowledge 14) privacy/confidentiality concerns

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4

Randeree 2007 U.S.A Orthopedics

1) cost

2) increase in staff workload 2) supplier presence

3) vendor trust 4) customizability 5) reliability

Qualitative 3 13 Interview All barriers

5 Miller et al. 2004 U.S.A Primary care

1) high initial financial costs 2) slow and uncertain financial payoffs 3) high initial physician time costs 4) complexity of technology

5) more extra to learn how to use 6) difficult complementary changes

7) inadequate support 8) inadequate electronic data exchange

9) lack of project champions 10) lack of incentives

Qualitative 90 Interview All barriers

6 Simon et

al. 2007 U.S.A Primary care

1) start-up financial costs 2) ongoing financial costs 3) loss of productivity 4) lack of computer skills 5) lack of technical support 6) lack of uniform standards 7) technical limitations of systems 8) concerns about privacy or security

9) organizational size 10) organizational type 11) lack of support from other organizations

Quantitative 1181 Questionnaire All barriers 7 Davidson et al. 2007 U.S.A All specialties 1) cost 2) reluctance to replace a recently acquired

system in order to integrate with an EHR 3) uncertainty about the vendor

4) workload to convert the records 5) waiting to see if subsides develop

8 Pizziferri et

al. 2005 U.S.A

Outpatient

primary care 1) more time per patient Qualitative 5 16

Observati

on Time 9 Shachak et

al. 2009 Israel Primary care

1) lack of proper typing ability 2) disturbing patient-doctor communication Qualitative 25

Interview + Observa-tion Patient-doctor communi-cation 10 Walter et al. 2008 U.S.A All

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11

Burt et al. 2005 U.S.A

Excludes anesthesio-logy, radiology and pathology

1) organizational factors of the practice Quantitative 3360 Questionnaire

Organiza-tional factors 12 Simon et al. 2007 U.S.A All specialties 1) organizational size 2) patient privacy concerns 3) lack of time

Quantitative 1345 Questionnaire All barriers 13 Earnest et al. 2004 U.S.A Clinic for congestive heart failure 1) privacy concerns

2) disturbing patient-doctor communication Qualitative

+ Quantitative

7 Interview 7 Questionnaire All barriers 14 Loomis et

al. 2002 U.S.A Family care

1) concerns about data entry

2) costs 3) security and confidentiality

4) lack of belief in EMRs

Quantitative 618 Questionnaire All barriers 15 Laerum et al. 2001 Norway All specialties 1) Access to computers 2) computer literacy 3) not flexible 4) traditional work routines

Quantitative 227 Questionnaire All barriers

16 Ludwick et

al. 2008 Canada Primary care

1) training and aftersales experience with the

vendor

2) technical support from the vendor

3) extra time for data entry 4) time constraint in procurement and

implementation 5) computer skills of the physicians

6) disruption of the flow of information

17 Valdes et

al. 2004 U.S.A Family care

1) cost 2) work slow-down 3) business failure 4) security concerns 5) standardization

Quantitative 5517 Questionnaire All barriers 18 Vishwanath et al. 2007 U.S.A All specialties 1) cost issues 2) ROI issues 3) lack of hardware

4) lack of financial incentives 5) logistics and regulatory issues

6) concerns over customization 7) herd mentality/social influence

8) need for control 9) concerns over adopting new technology

10) lack of community level participation

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19 Meade et al. 2009 Ireland All specialties 1) lack of time 2) cost 3) poor training 4) absence of computer skills 5) lack of financial resources 6) lack of typing ability

7) fail to find a suitable system

20 Kemper et

al. 2006 U.S.A Pediatric

1) expense of implementation 2) inability to find an EHR that meets the

requirements 3) inability to interface with existing practice

systems

4) system downtime

5) lace of clear return on investment 6) transience of vendors

7) increase in physician workload 8) no improvement in patient care or clinical

outcomes

9) increase in staff workload 10) staff have inadequate computer skills

11) interference with doctor-patient relationship 12) patient confidentiality

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Master’s Thesis 14

2. Taxonomy of Barriers

An overview of all barriers, mentioned in twenty included studies, was shown in Table 1. In order to have a general picture of the barriers towards EMRs by physicians, barriers meeting similar problems were sorted into one category. Thus, all barriers listed in Table 1 were categorized into eight categories, each of which includes its relevant sub-barriers.

(1) Category A: Financial

The "Financial" category of barriers is related to the monetary issues involved in the implementation of EMRs. Considering about implementing a new system, the monetary aspect is the key factor for physicians. The questions for the physicians normally are whether the costs of implementing and running an EMR system are affordable and whether they can get a financial benefit from it. The costs of an EMR system can be divided into two groups: start-up costs and ongoing costs. Some researchers do not distinguish between specific kinds of costs in their studies, but it can be assumed that two kinds of costs are included in these studies. This is due to the fact that implementing an EMR is a complete process with different stages, involving the costs in purchase, coordination, monitoring, upgrade and governance. The financial barrier is the most frequently mentioned barrier among the 20 included studies.

1) High start-up costs

Start-up costs include all expenses needed to make EMRs start working in the practice first, such as the purchase of hardware and software, selecting and contracting costs and installation expenses. These costs range from $16,000 to $36,000 per physician, as typically EMR software costs already approximately $10,000 per physicians (Randeree, 2007; Miller et al., 2004). Many researchers state that these costs are significantly high and therefore have to be regarded as an immense barrier for physicians to adopt EMRs, especially for those without large IT budgets. Among 20 included studies, four of them, with the detailed survey results shown, emphasize that the high start-up costs are listed as a primary and major barrier to EMR adoption. (Jha et al., 2009; DesRoches et al., 2008; Menachemi et al., 2007; Randeree, 2007; Miller

et al., 2004; Simon et al., 2007; Davidson et al., 2007; Loomis et al., 2002; Valdes et al., 2004;

Vishwanath et al., 2007; Meade et al., 2009; Kemper et al., 2006) 2) High ongoing costs

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Master’s Thesis 15 and maintaining EMRs, which will continuously cause high costs. Additionally, venders charge a lot of money for after-sales service. All of these result in an unwillingness of physicians to adopt EMRs (Jha et

al., 2009; DesRoches et al., 2008; Menachemi et al., 2007; Randeree, 2007; Simon et al., 2007; Davidson et al., 2007; Loomis et al., 2002; Valdes et al., 2004; Vishwanath et al., 2007; Meade et al., 2009;

Kemper et al., 2006).

3) Uncertainty about Return on Investment (ROI)

As implementing and maintaining EMRs is very costly, physicians are worried that their practices will face substantial financial risks and that it could take years before there comes a return on the investment (Miller et al., 2005). According to Miller and Sim (2004), “financial benefits vary greatly, from none in practices that made few work practice changes to more than $20,000 per physician per year in the few practices that eliminated most paper processes” (Miller & Sim, 2004, p.119). While EMR vendors claim that the benefits outweigh the costs, physicians still observe this issue with caution (DesRoches et al., 2008; Menachemi et al., 2007; Randeree, 2007; Miller et al., 2004; Valdes et al., 2004; Vishwanath et al., 2007; Kemper et al., 2006).

4) Lack of financial resources

Only few researchers directly point out that the lack of financial resources / funds is a problem towards the EMR adoption (Meade et al., 2009). However, the high start-up and ongoing costs of implementing an EMR (Barrier A1 & A2) result in the problem of insufficient financial resources in medical practice. As these costs are very high, there are not enough financial resources to cover them, especially for small and medium sized practices with insufficient IT-budget.

(2) Category B: Technical

Electronic Medical Records are Hi-tech systems, which include complex hardware and software. A certain level of computer skills of suppliers and users - the physicians - is required to deal with the systems. Besides, there are still some technical problems of EMRs, which are complained by physicians and need to be improved. Therefore, barriers related to the technical issues of the systems, technical capabilities of the physicians and of the suppliers are discussed in this category.

1) Lack of computer skills of the physicians and / or the staff

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Master’s Thesis 16 Simon et al., 2007; Laerum et al., 2001; Ludwick et al., 2008; Meade et al., 2009; Kemper et al., 2006). Meade et al. (2009) state in this context that most of the current generation of physicians in Ireland got qualified before the introduction of IT programs. EMR providers underestimate the level of computer skills required from physicians, while the system is seen as and actually is very complex to use for these physicians (Barrier B3). In the research of Ludwick et al. (2008), some physicians report that they sometimes stop using EMRs, because the hunting for menu and buttons disrupts the clinical encounter. Besides, proper typing skills for patient medical information, notes and prescriptions in order to use EMRs are required, which some physicians lack of. Shachak et al. (2009) find out that the EMR-use provokes new types of medical errors – typos. Furthermore, not only the physicians, but also other staff of the medical practices, have inadequate computer skills. Thus, this makes the wide adoption of EMRs more difficult to get realized.

2) Lack of technical training and support

Many physicians complain about their experience of poor service from the vendor, such as poor follow-up with technical issues and a general lack of training and support for problems with the EMRs (Randeree, 2007). Ludwick et al. (2008) point out that physicians struggle to get appropriate technical training and support for the systems from the vendor. As physicians are no technical experts in using the EMR system (Barrier B1) and the system itself is of complicated nature (Barrier B3), they are reluctant to use EMRs without proper technical training and support. Simon et al. (2007) investigate that two-thirds of physicians indicate a lack of technical support as a barrier to the adoption of EMRs, while some physicians report a missing access to vendor technical support (Ludwick et al., 2008).

3) Complexity of the system

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Master’s Thesis 17 4) Limitation of the system

Some physicians worry about the condition that EMRs are machines - systems made and programmed by IT companies. Under certain circumstances or as time passes, the systems will meet their limitations, become obsolete and will not be useful anymore (DesRoches et al., 2008; Simon et al., 2007).

5) Lack of Customizability

According to Randeree (2007), “customizability refers to the ability of the technology systems fails to conform to specific needs of the user applications” (Randeree, 2007, p.494). Many surveys show that one reason why physicians do not accept EMRs is that they could not find a system to meet their special needs or to utilize it to their requirements (DesRoches et al., 2008; Menachemi et al., 2007; Randeree, 2007; Miller et al., 2004; Simon et al., 2007; Vishwanath et al., 2007; Kemper et al., 2006). Some physicians may also use the lack of customizability as an excuse to avoid EMRs, due to other reasons (for example, Barrier B1, C2, C3 & D2). However, more effort from the vendors of EMRs for its customizability is required. This customer-made service will raise the practices’ costs to implement EMRs, which arouses the financial barriers (Barrier A1, A2 & A4).

6) Lack of Reliability

“Reliability is the dependability of the technology systems that comprise the EMRs” (Randeree, 2007, pp.493-494). High reliability is very important for a system dealing with information. However, many physicians are concerned about the temporary loss of access to patient records if computers crash, viruses attack and power fails (Menachemi et al., 2007; Randeree, 2007; Kemper et al., 2006). Moreover, there may be a possibility of record loss due to an unknown technical defect of the system. Furthermore, the problem of reliability will cause financial loss, such as an increase of ongoing costs (Barrier A2).

7) Interconnectivity / Standardization

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Master’s Thesis 18 industry. Thus, it makes the data not exchangeable through different systems (Menachemi et al., 2007; Miller et al., 2004; Simon et al., 2007; Vishwanath et al., 2007; Meade et al., 2009; Kemper et al., 2006). Furthermore, smaller practices face this problem more seriously than the larger ones, since larger practices have more organizational resources like expertise and experience.

8) Lack of computers / hardware

The use of EMR systems requires a sufficient quantity of hardware in practices, such as computers, phone lines and internet connection. On the one hand, researchers state that some practices lack of these basic facilities / hardware to support the implementation of EMRs (Laerum et al., 2001; Vishwanath et al., 2007). This issue blocks the wide adoption of EMRs. On the other hand, the start-up costs for the preparation of setting up EMRs will increase and more financial resources are needed. Both incidents are barriers mentioned in the “Financial” category (Barrier A1 & A4). As a consequence, only few researchers directly refer to the unavailability problem of computers / hardware.

(3) Category C: Time

A fluent workflow is very important for the work of physicians. However, the introduction of EMRs will slow down the physicians’ workflow, as it will always cause extra time for them to select, implement and learn how to use EMRs and even to enter data into their systems. As a result, their productivity will be reduced and their workload will be increased. This will cause financial problems, such as low revenue.

1) Time to select, purchase and implement the system

It is investigated that physicians choose not to invest time in system selection and procurement (Jha et al., 2009; Menachemi et al., 2007; Ludwick et al., 2008; Meade et al., 2009), as they think they should spend more time and effort on patients, instead of selecting and contracting an EMR, which is not regarded as their daily working practice. However, there is no clear statement whether the physicians should be responsible for this part of work. Therefore, whether the investment of time in selecting, purchasing and implementing by physicians is really a barrier depends on the quality of project management during the implementation of EMRs.

2) Time to learn the system

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Master’s Thesis 19 and work on learning how to use this system. However, “the demands and pressures of delivering office-based care may not afford them the time to learn the system” (Simon et al., 2007, p.511). Therefore, they report that they lack of time to learn, as it will slow down their workflow and increase their workload. Moreover, other researchers argue that mastering the EMR system will help the physicians to work more efficiently (Meade et al., 2009). Maybe further studies on benefit-effort analysis should demonstrate the high value of learning the system.

3) Time to enter data

It is surprising that many researchers conclude that data entry is a problem for physicians in handling the EMRs (Menachemi et al., 2007; Loomis et al., 2002; Laerum et al., 2001; Ludwick et al., 2008; Valdes et

al., 2004; Kemper et al., 2006). In Loomis (2002) research, more than half of EMR users state that it is

cumbersome and time-consuming to enter data into EMRs. Data-entry is really a widely experienced barrier among physicians. It can be related with the complexity of the system (Barrier B3), or the inability of physicians to handle the system properly (Barrier B1), both mentioned in the “Technical” category. 4) More time per patient

Many physicians report that using EMRs will cost more time per patient than using paper, as in some situations, it might be more convenient and efficient to use paper records during the clinical encounter (Laerum et al., 2001). When using EMRs, physicians have to stop during the halfway of the encounter in order to fill in information of patients or type prescription, which will disrupt their overall workflow. Additionally, due to the reason that physicians are slow in typing and entering data (Barrier C3), it will cost more time for each patient visit than before. Focusing on this issue, Pizziferri et al. (2005) carry out a time-motion study on physician time utilization before and after implementation of an EMR. They find out that most physicians are able to avoid “sacrificing time with patients or overall clinic time, but they do spend more time on documentation outside of clinic sessions” (Pizziferri et al., 2005, p.183). Finally, using EMRs does increase a physician’s workload. However, there are no other studies focusing on this issue to further prove the obtained results. Based on the technical problems introduced before, such as lack of computer skills of physicians (Barrier B1) and the complexity of the EMR system (Barrier B3), the ease of use of an EMR is a key element of the efficiency and the acceptance of this system.

5) Time to convert the records

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Master’s Thesis 20 themselves would make of handwritten notes, histories, and so on” (Davidson et al., 2007, p.25). They are aware of the burden and time cost of record conversion, which may outweigh the acknowledged potential benefits of EMRs. As a result, the converting time of records is considered as a barrier to integrate EMRs into medical practices.

(4) Category D: Psychological

Physicians have concerns toward the use of EMRs, based on their personal issues, knowledge and perceptions. Their perception of quality improvement related to EMRs and worries about losing their professional autonomy are included in this category.

1) Lack of belief in EMRs

According to Kemper et al. (2006), more than half (58.1%) of the physicians without an EMR share a lack of belief that EMRs can improve patient care or clinical outcomes. Other researchers state that those who are unwilling to use the system still hold their skepticism that EMRs can be successful in quality improvement of medical practices (Jha et al., 2009; Simon et al., 2007; Vishwanath et al., 2007). This causes a personal resistance in the adoption of EMRs. However, it is just an expected barrier toward EMRs by EMR non-users, as there are not valid statistical data and success stories about EMRs available for them. Implementing EMRs means a change for physicians in their working styles. Initially, people are afraid of change and doubt the necessity of change itself. Besides, the physicians’ skepticism and negative perception towards EMRs are affected by the social influence around them, which will be discussed in the “Social” category.

2) Need for control

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(5) Category E: Social

Instead of working alone, physicians in medical practices work together and cooperate with other parties in the healthcare industry, such as vendors, subsides, insurance companies, patients, administrative staff, managers. The decision-making process of EMR implementation of physicians is influenced by these parties and will also affect the relationship between physicians and patients. This interrelated relationship between the physicians’ decision and the relative parties is categorized as "Social" barriers.

1) Uncertainty about the vendor

As mentioned in the “Technical” category, a lack of technical training and support from the vendor is reported as a barrier in the adoption of EMRs by physicians. Therefore, the qualification of vendors of EMR systems is crucial for the acceptance of EMRs. EMR systems are still relatively new in the marketplace (Randeree, 2007). The lack of suitable vendors reflects an immature industry, without enough viable products and competitors available to offer better services and enough information about the vendors. Physicians are concerned that the vendors are not qualified to provide proper service, or will go out of business and disappear from the market, leading to a lack of technical support (Barrier B2) and a large financial loss (Barrier A3) (Randeree, 2007; Davidson et al., 2007; Kemper et al., 2006). Additionally, as a result of the high costs of implementing EMRs, physicians are unwilling to enter this market without the guarantee of reputable and trustworthy vendors.

2) Lack of support from external parties

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3) Interference with doctor-patient relationship

Only few researchers in the included studies realize the interaction problem between the doctors and the patients when using EMRs. When this issue is taken into consideration, 92% physicians in Shachak’s research (2009) feel EMR use disturbs the communication with their patients. Physicians have to turn to the computer to complete electronic forms during the encounter, consuming plenty of time, as they suffer from limited computer skills (Barrier B1). According to Shachak et al. (2009), the average screen gaze of physicians is from 25% to 55% of the visit time when using EMRs, which results in less eye-contact and less conversation with the patients. Otherwise, it will cause the physicians more time per patient, which is pointed out in the “Time” category (Barrier C4). In addition, as some EMRs are patient-accessible, it might even distort the clinical encounter with more patients’ interferences and distractions (Earnest et al., 2004). In that sense, the traditional doctor-patient relationship will be changed by EMRs. Whether it is a problem for physicians and patients should be the topic of more empirical research, since it is till now neglected by most researchers.

4) Lack of support from other colleagues

Physicians are working cooperatively with other colleagues, such as nurses and administrative staff, in medical practices. The lack of technical skills, complaint in workload increase, negative perceptions and resistance in using EMRs, which are mentioned in the previous categories, do exist as well in the view of these colleagues. A lack of support from these colleagues impedes the physicians from further adopting the system (Randeree, 2007; Vishwanath et al., 2007). Only few researches recognize that this lack of support may be a barrier for physicians to adopt EMRs.

5) Lack of support from the management level

Whether the management level supports the use of EMRs and believes in the benefits of EMRs will influence the rate of EMR adoption of physicians (Miller & Sim, 2004; Vishwanath et al., 2007). However, most researchers do not realize this issue or take a commitment in the implementation of EMRs by managers for granted. This issue will be further discussed in the “Change Process” category (Barrier H4).

(6) Category F: Legal

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Master’s Thesis 23 otherwise it will cause legal issues. However, there is a lack of clear security standards which can be obeyed by those who are involved in the use of EMRs.

1) Privacy or security concerns

An issue agreed by many researchers is that the use of EMRs with computers may have a negative effect on patient privacy (Jha et al., 2009; Menachemi et al., 2007; Simon et al., 2007; Earnest et al., 2004; Loomis et al., 2002; Valdes et al., 2004; Vishwanath et al., 2007; Kemper et al., 2006). Physicians doubt whether EMRs are a secure place to store patient’s information and records, as data in the system may be accessible to those who are not authorized to obtain it. As a result, inappropriate disclosure of patient information might cause legal problems. Furthermore, there are no clear security regulations to ensure patient privacy and confidentiality. According to Simon et al. (2007), the physicians are more concerned about this issue than the patients themselves. Therefore, this issue has to be regarded as one of the biggest barriers in adopting EMRs. Most physicians, who currently use EMRs, still believe that there are more security and confidentiality risks involved with EMRs than with paper records (Loomis et al., 2002). This shows that concerns about privacy and security of patient data are an experienced barrier of EMR users.

(7) Category G: Organizational

Medical practices and hospitals are the places where physicians are working. The organizational characteristics of practices are associated with the adoption of EMRs. Physicians with different sizes and types of practices may have different attitudes toward EMRs.

1) Organizational size

From surveys made by Miller et al. (2004), Simon et al. (2007) and Burt et al. (2005) show that physicians in larger medical practices have a higher rate of EMR adoption than those in smaller practices. They also found out that “physicians in larger practices are more likely to use available functions in their EMRs than those with EHRs in smaller practices” (Simon et al., 2007, p.511). One reason for this result is that the physicians in larger organizations have more extensive systems for supporting and training (Barrier B2) in the use of EMRs. In turn, the organizational size also influences the time required for selecting, purchasing and learning the system, converting and entering data and patient visit (Barrier C1, C2, C3, C4 & C5).

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Master’s Thesis 24 stronger organizational resources such as management expertise, practical experience, financial resources, or support staff (Miller & Sim, 2004). In addition, Randeree (2007) emphasizes that small sized practices have a more serious cost problem connected with EMRs than large practices do. Small practices do not have a large IT budget, which supports the implementation and run of the system. Although some researchers realize the differences in EMR adoption between small and large practices, they do not analyze these problems or the reasons behind respectively. Further thorough study is needed to fill this gap.

2) Organizational type

Simon et al. (2007) state that whether a practice is affiliated with a hospital is an important driver of EMR adoption. According to Burt and Sisk (2005), physicians who are employed or contracted in a medical practice are more likely to use EMRs than those who own their own practices. Solo physicians are more likely to cite high start-up and ongoing costs, lack of technical training, lack of uniform standards, lack of time, lack of belief in EMR’s effectiveness and confidentiality concerns as the major barriers in EMR adoption. Among 20 included studies, only few relate the element “organizational type” with the adoption of EMRs (Simon et al., 2007; Burt et al., 2005). However, from the perspective of “organizational type”, more qualitative studies for further analysis may be required.

(8) Category H: Change Process

Implementing EMRs in medical practices means a big change for physicians, as they have their own special working styles for years. This makes them unwilling to make or adapt to any change in their work. Therefore the change process itself is a challenge as well as a problem. Most researchers only focus on individual physicians and EMR system, instead of considering the change process. Problems occurring during the change process, such as lack of proper organizational culture, lack of incentives, individual and local resistance, lack of community level participation and lack of leadership, are discussed in this category.

1) Lack of support from organizational culture

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Master’s Thesis 25 “technology alone is not sufficient to achieve a well functioning electronic information system” (Laerum

et al., 2001, p.1347). Working in new ways also needs the change in certain organizational aspects. The

EMR-friendly culture supports the organization-wide use of EMRs. How to create a proper organizational culture for the use of EMRs is an important topic for further research on how to implement EMRs successfully.

2) Lack of incentives

EMRs have potential benefits in quality improvement of medical care. However, if the physicians see no personal benefit from using EMRs, they will not be motivated to use it and thus stick to their traditional working procedures. Without personal incentives of physicians during the implementation of EMRs, the adoption of EMRs will not reach its expected level (Miller & Sim, 2004, Vishwanath et al., 2007). Financial rewards are almost the only cited incentive in the studies.

3) Lack of participation

Only one article out of 20 studies mentions the problem of a lack of participation (Vishwanath et al., 2007). Participants include not only physicians, but also nurses, administrative staff, IT staff and other organizational members. Wide adoption of EMRs can only be reached if all organizational members participate in the use of EMRs. However, this problem shows up due to the existence of other barriers, such as a lack of leadership (Barrier H4), a lack of supportive organizational culture (Barrier H1) and a lack of support from other colleagues (Barrier E4). Therefore, this problem is mainly caused by other factors, which may be the reason why most researchers do not refer to it separately.

4) Lack of leadership

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Table 2 Taxonomy of Barriers

Category Barriers References (Article No.)

A Financial

High start-up costs 1/2/3/4/5/6/7/14/17/18/19/20 High ongoing costs 1/2/3/4/6/7/14/17/18/19/20 Uncertainty about Return on

Investment (ROI) 2/3/4/5/17/18/20 Lack of financial resources 19

B Technical

Lack of computer skills of the

physicians and / or the staff 1/3/6/9/15/16/19/20 Lack of technical training and support 1/4/5/6/16/17/18/19/20 Complexity of the system 3/5

Limitation of the system 2/6

Lack of Customizability 2/3/4/18/20 Lack of Reliability 3/4/20

Interconnectivity / Standardization 3/5/6/7/17/18/19/20 Lack of computers / hardware 15/18

C

Time

Time to select, purchase and

implement the system 1/3/16/19 Time to learn the system 1/3/5/12/19/20 Time to enter data 3/14/15/16/17/20 More time per patient 3/5/6/8/15/16/17/20 Time to convert the records 5/7

D Psychological Lack of belief in EMRs 1/18/20

Need for control 10/18

E Social

Uncertainty about the vendor 4/7/20 Lack support from external parties 6/7/18 Interference with doctor-patient

relationship 9/13/20

Lack of support from other colleagues 4/18 Lack of support from the management

level 5/18

F Legal Privacy or security concerns 1/3/6/12/13/14/17/18/20 G Organizational Organizational size 4/5/6/11/12

Organizational type 6/11

H Change Process

Lack of support from organizational

culture 4/15

Lack of incentives 5/18 Lack of participation 18

Lack of leadership 5/18

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IV. Analysis

1. Relationship among the Barriers

From the obtained results, it can be seen that barriers of different categories or subcategories are interrelated with each other. For instance, high start-up costs and on-going costs (Barrier A1 & A2) cause a lack of financial resources (Barrier A4); lack of proper computer skills of physicians (Barrier B1) is the reason why physicians need to take more time to learn the system (Barrier C2).

Furthermore, more attention should be paid to the last two categories – the “Organizational” (Category G) and the “Change Process” (Category H) categories. The barriers in these two categories are related with the characteristics of medical practices and the EMR implementation project itself. They affect the importance level of other barriers in the previous six categories. However, they influence other 6 barrier categories in two directions.

The “Organizational” category determines the relative importance of barriers even before the implementation, as characteristics of the practice can affect the difficulty level of certain barriers. For example, if a practice is small, it is expected to meet more difficulties in financial issues than a big practice.

The “Change Process” category can mediate other identified barriers during the implementation process, in order to overcome them and reach a high EMR adoption rate. Otherwise, the ignorance of this category will cause more serious barriers in categories A-F. Therefore, Category G and Category H can be seen as the mediating factors of success of an EMR project. The relationship among the barriers is illustrated in

Figure 2.

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2. Measuring the presence and importance of the barriers

One purpose of this research is making relevant interventions to minimize the most important barriers, in order to accelerate EMR adoption by physicians. Therefore, an analysis of the presence and importance of these barriers, with the use of a Barrier Matrix (See Figure 3), is carried out.

This Barrier Matrix, consists of two axes, a horizontal axis, called “Relative importance of barrier”, and a vertical one, named “Presence of barrier”. Based on these two axes of “Presence of barrier” and “Relative importance of barrier”, the matrix contains four quadrants, which are “Quadrant 1: Unimportant barriers”, “Quadrant 2: Important barriers”, “Quadrant 3: Important non-barriers” and “Quadrant 4: Unimportant non-barriers”.

In order to integrate each category of the barriers in the Matrix, only 9 pure quantitative researches, each of them focusing on all barriers, are included in this analysis. This is due to the following reasons: 1) those researches that have a specific focus (See Table 1) have a bias in certain barriers; 2) those non-quantitative researches, including qualitative researches, mixed research and concept-mapping research, have a biased sample and their sample size is too small. Therefore, they are not comparable with those in quantitative researches.

Besides, as mentioned before, Category G “Organizational” and Category H “Change Process” are mediating conditions for other barrier categories. Therefore, they are excluded in this matrix. However Category G “Organizational size” will be used as a condition to show the different importance of barriers in large and small organizations.

Figure 3 Barrier Matrix

Source: Author’s own figure, ideas suggested by Prof. A. Boonstra and Dr. H. Broekhuis.

Low Relative importance of barrier High

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Master’s Thesis 29 If one category of barriers is mentioned in 4 or more of the 9 quantitative researches (Article 1, 2, 3, 6, 12, 14, 17, 19, 20 – see Table 1), the “Presence of barrier” is defined as “High”, otherwise, it is defined as “Low”. The samples of these 9 studies are summed up as a whole sample pool, with a new sample size of 20231. The reporting rate of each barrier category is calculated, based on the new sample pool, to identify its importance. The category which is rated more than 45% is defined as “High” in “Relative importance of barrier”, otherwise it is defined as “Low”. More attention should be paid to categories A, B and C. “AA”, “BB” and “CC” represent categories A, B and C respectively in large organizations, while “A”, “B” and “C” represent categories A, B and C respectively in small organizations. Different positions of “AA” (“BB”, “CC”) and “A” (“B”, “C”) in one quadrant mean different relative importance levels of the same category in large and small organizations. Whether a barrier is more or less important for a small or big organization, was already mentioned in the “Results” part” in chapter 3 as an outcome of the analysis of respective researches. Therefore, the identified Barrier Matrix looks as follows (Figure 4):

First, based on the data from the 9 included studies, barriers in Category A “Financial” and Category C “Time” are important barriers. As shown in Figure 4, they are relatively more important for smaller practices than for the larger ones. In other words, it is more difficult for the smaller practices to overcome these barriers in the respective categories than for the larger practices.

Low Relative importance of barrier High

L ow P res enc e of ba rr ier H igh

Figure 4 Identified Barrier Matrix F BB B Unimportant barriers CC C AA A Important barriers D E Unimportant non-barriers Important non-barriers

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Master’s Thesis 30 Second, barriers in Category B “Technical” and Category F “Legal” are unimportant barriers, since they are frequently mentioned in these 9 studies, but their reporting rates are not that high. However, more physicians in small practices report technical barriers than those in large practices. In that sense, it is more difficult for smaller practices to solve technical problems than for larger practices.

Third, barriers in Category D “Psychological” and Category E “Social” are listed as unimportant non-barriers. From the perspective of qualitative researches, the presences of categories A “Financial”, B “Technical”, C “Time”, D “Psychological” and F “Legal” are similar with those in the matrix. While Category E “Social” is regarded as unimportant non-barrier according to the 9 quantitative researches, most qualitative researches point out that it is a frequently-presented barrier. Therefore, in future research, more attention should be paid to social barriers to explore its influence in physicians’ EMR adoption.

3. Change Approach

Implementing EMR systems in a medical practice involves changes, not only on the individual or group level, like working behaviors of organizational members, but also on the organizational level, like organizational cultural change. Besides, some changes can be slow, while others can be rapid. For these reasons, the combination of “Planned Change” and “Emergent Change” will be quite appropriate in the EMR implementation process. The change process should start with “Planned Change”, based on the key steps defined in advance, followed by “Emergent Change” in case of unexpected change needs. Furthermore, “Planned Change” will be the main part in the whole process, while “Emergent Change” will be made when necessary.

Hence, the Three-Step Model of Lewin (Burnes, 2004) can be applied to the EMR implementation. Its three steps are:

1) Unfreezing - to arouse the needs of change (the use of EMRs);

2) Moving - to move from old working behaviors and procedures (paper system) to new ones (EMR system);

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4. Interventions

Overcoming the barriers to the acceptance of EMRs is not a one-party job. Instead, it needs support from different parties, like the government, policy makers, payers, insurance companies, vendors, management level in the practice and patients. However, in this paper, the intervention issues are investigated in the perspective of EMR implementers in medical practices, like managers, project leaders and change managers. In that sense, some barriers listed before are out of their control. For instance, overcoming the high-cost barrier, especially the purchase cost of EMRs, may require incentives by payers and the government, such as low-interest loans or funding programs (Anderson, 2007). According to Anderson (2007), regarding privacy and security concerns (Barrier F1), a comprehensive set of national privacy laws on data protection, regulated by the national government, are strongly required. In addition, the best option to solve the barrier of uncertainty of the vendors (Barrier E1) will be the availability of certification of a vendor’s qualification. This can only be realized through the effort and support of an authorized association or institution, instead of one medical practice.

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Table 3 Interventions and Related Barriers

No. Intervention Related Barriers

Step 1 Unfreezing

1 Realign the priority of medical practices to medical

/ patient safety A1, A2, A4

2 Offer early education and open communication

within the practice B2, B3, B4, D1, H1, H3

Step 2 Moving

3 Identify a champion / champions and set up a

management team for EMR implementation project H4 4 Offer comprehensive and continuous technical

training throughout the practice B1, B2, C2, C3 5 Form own IT team for EMR implementation and

hire external IT consultants A2, B2, C1

6 Out-source external consultants to assist in the

implementation process B7, C1, F1

7 Set up a date to redesign the work flow in the

practice and clarify work roles E4

Step 3 Refreezing

8 Re-design the rewarding system H2

Source: Author’s own table.

Step 1 Unfreezing

1) Realign the priority of medical practices to medical / patient safety

This means creating a vision for change (Lorenzi et al., 2009). For example, the vision can be “our practice will have an electronic integrated information system in order to reach zero medical error”. For the implementers, it is impossible to change the reality of high costs of EMRs. However, by setting medical / patient safety as a priority, the practices can put the budgets for other projects aside to collect sufficient capital for EMRs (Barrier A1, A2 & A4) (Poon et al., 2004).

2) Offer early education and open communication within the practice

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Master’s Thesis 33 have to realize the necessity to make a change in their working routines. The success-stories in other practices, with a change of medical errors in statistic data before and after the EMR implementation, should be published. Relative information should be collected and spread within the practices to demonstrate that a new system will be more favorable than the old one. The experts in medical safety or EMR pioneers should be invited to give a speech or meeting. This helps to strengthen physicians’ belief in the use of EMRs and their benefits in medical quality improvement (Barrier D1). Also physicians will realize the need of changing paper systems into EMR systems.

Besides, there should be an open and honest communication with the users or the potential users of EMRs. It will help them to understand the fact that it may take some time to learn or to enter data into the system, and that they may meet some difficulties during the implementation, but there will be impressive payoffs afterwards (Ash & Bates, 2005). An open communication aims at alleviating physicians’ concerns about extra time to learn, enter data in the system and to complete a patient visit (Barrier B2, B3 and B4). Meanwhile, the understanding that EMRs are not just a system for technology replacement (from paper to electronic system) is needed. It is more a fundamental change in their workflow and work style.

In addition, open communication about EMRs encourages physicians, as well as the staffs, to provide their feedback about the strengths and weaknesses of EMRs to the management team after using it. This will help the management team to better understand physicians’ needs and requirements in the use of EMRs. If possible, IT teams, external IT consultants or even the venders can provide updates and adjustments according to these feedbacks. With the help of a two-way open communication, the physicians are not only well-informed but also well-heard during the process of EMR implementation. So they will be more willing to participate in the project. “Involving people from the very beginning helps them to feel part of the process” (Lorenzi et al., 2009, p.7). Therefore, it will lead to a higher participation rate (Barrier H3) and a higher adoption rate of EMRs. Meanwhile, the culture of using EMRs to improve medical care quality will be created (Barrier H1).

Step 2 Moving

3) Identify a champion / champions and set up a management team for an EMR implementation project

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Master’s Thesis 34 EMR management team. Besides, select one or two management representatives from different departments as the members of a management team, to strengthen the leadership in an EMR implementation project. The leaders have to be firm believers in EMRs and have to make a visible commitment to the EMR implementation project (Barrier H4) (Poon et al., 2004). Lorenze et al. (2009) state that every member in the practice should respect, trust and communicate effectively with the leaders. 4) Offer comprehensive and continuous technical training throughout the practice

In order to implement a new EMR system in the practice, comprehensive and continuous technical training is essential for both physicians and other staff. This training will help to overcome the limited knowledge of using the system. The training courses should be offered in different levels, from basic level (e.g. the use of a computer and mouse), to advanced level (e.g. the effective use and maintenance of an EMR system). Thus, physicians, as well as other practice members, will get different training courses based on their computer skills and technical knowledge. These training courses should be offered in repeated groups to make sure that everyone in the practice has the opportunity to access these courses when needed. In case of time conflicts or special circumstances, one-to-one training, especially for the physicians, should also be available at convenient times and locations (Clayton et al., 2005). One-to-one training can be given by the super-users or IT staff in the practices. Group training and one-to-one training, combined with a more flexible time schedule, will enable both physicians and staff to deal with EMR systems technically (Barrier B1, B2, C2, C3), as this is the key factor for successful EMR implementation.

5) Form an own IT team for EMR implementation and hire external IT consultants

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Master’s Thesis 35 6) Out-source external consultants to assist in the implementation process

As mentioned before, EMRs need to be interconnected with other devices to generate benefits. However, EMR vendors and other device suppliers tend to provide technical support only for their own products (Miller & Sim, 2004). Besides, knowledge and experience of internal IT team are limited. Therefore, the cooperation with external IT consultants, or an IT consulting company, is necessary during the whole implementation process, especially for small practices. As external IT consultants are familiar with different systems and devices from different suppliers, their advice is very helpful and reduces time, workload and risks for the physicians in selecting and purchasing the systems (Barrier C1). For the same reason, they are more experienced in complementary changes between EMRs and other products, as they may have accomplished similar projects before. Moreover, they have sufficient specialized professionals within their organizations. Therefore, hiring external consultants makes it easier to handle the interconnectivity problems (Barrier B7).

Furthermore, non-profit organizations, which are officially recognized by the government and committed to accelerating the adoption of EMRs, such as the Certification Commission for Healthcare Information Technology (http://www.cchit.org), can be consulted as well. Non-profit organizations and physicians can especially discuss the issues of product or vender selection, EMR functionality, interoperability and security, as these organizations have already developed the standards, inspection processes and policies needed for health IT systems (Simon et al., 2007). Thus, for physicians, the time spent on selection, worries about the EMR itself and data privacy / security will be reduced (Barrier B7, C1, F1).

7) Set up a date to redesign the work flow in the practice and clarify work roles

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Master’s Thesis 36 Besides, with the change of work flow, working in new ways means disruption of established work roles and creation of new roles. Roles and responsibilities should be clarified clearly. For example, the task of data conversion from paper to electronic systems will be assigned to certain staff in each department. If an unclear item shows up, the corresponding physicians need to be informed and consulted. In order to identify who will lead a project activity or who will play an important role in the specific project activity, a Responsibility Assignment Matrix (RAM) should be used to indicate relationships and responsibilities.

Step 3 Refreezing

8) Re-design the rewarding system

Financial incentives are the motivation for the physicians to get rid of paper-based working routines and further adopt EMR. An alternative approach is to offer differentiated payments that reward or directly reimburse physicians for adopting EMRs or for achieving specific quality outcomes through the use of EMRs (Barrier H2), such as “performance bonuses or payments through add-on codes” (Rosenfeld, 2005, p.1142).

Moreover, new work roles need support from a new rewarding system. The outcome-based payment is typically called as “pay-for-performance”. Already some examples of “pay-for-performance” programs in practice exist. For instance, one model implemented in the United Kingdom connects 30 percent of physicians’ salaries with their performance based on a complex set of parameters measured through EMRs (Bates, 2005).

Barriers to the Acceptance of Electronic Medical Records by Physicians

MASTER’S THESIS