ENABLING FACTORS FOR ACHIEVING GREATER
SUCCESS IN ELECTRONIC MEDICAL RECORD INITIATIVES
Wilfred Bonney
School of Business and Technology, Capella University, Minneapolis, MN, U.S.A.
Keywords: Electronic medical record, Interoperability, Health data standards, Critical success factors.
Abstract: The introduction of Electronic Medical Record (EMR) systems in the healthcare industry has brought
anticipation as to whether the use of the system is enabling or constraining healthcare providers’ efforts in
providing efficient healthcare services and evidence-based practice. Although few EMR systems have
managed to achieve success in the healthcare industry, many have failed to meet the expectations of
healthcare providers and the general public. In this paper, a literature review was used to explore the
possible trends or factors which may help future electronic medical record initiatives achieve greater
success and less failure. The practical and research implications for implementing successful EMR
initiatives are also discussed.
1 INTRODUCTION
The practice of collecting and storing patient’s
information in computerized medical information
systems, rather than paper charts has increasingly
gained popularity amongst many healthcare
providers (Adler-Milstein and Bates, 2010; Harrison
and Ramanujan, 2011; Hsieh, 2010). In their attempt
to promote awareness about the under-utilization of
Information Technology in the healthcare sector,
Adler-Milstein and Bates (2010) noted that the use
of computerized medical information systems have
the potential to support evidence-based practice and
transform how care is delivered to patients. Adler-
Milstein and Bates (2010) posited that Information
Technology is “increasingly being considered a
natural tool for aiding providers, as computers can
easily store up-to-date information on domains like
medications and their contraindications” (p. 120).
These considerations have accelerated the
development of Electronic Medical Record (EMR)
systems and promoted their continuing use and
adoption in medical practice.
However, the introduction of EMR systems in
the healthcare industry has also brought anticipation
as to whether the use of the system is enabling or
constraining healthcare providers’ efforts in
providing efficient healthcare services and evidence-
based practice. Although few EMR systems have
managed to achieve success in the healthcare
industry, many have failed to meet the expectations
of healthcare providers and the general public
(Gagnon et al., 2010). This failure has resulted in the
slow implementation of EMR initiatives in the
healthcare industry (Boonstra and Broekhuis, 2010;
Brooks and Grotz, 2010).
The objective of this paper is to explore the
possible trends or factors which may help future
electronic medical record initiatives achieve greater
success and less failure. The first part of the paper
gives an overview of electronic medical record. In
the second part, the focus is on the enabling factors
that will enable future EMR initiatives to achieve
greater success. The third part discusses the practical
and research implications for implementing
successful EMR initiatives.
2 METHOD
A literature review, based on research articles from
2001 to 2011, was used to explore the possible
trends or factors which may help future electronic
medical record initiatives achieve greater success
and less failure. The methodology involves a review
of relevant publications, found and accessed with the
help of ProQuest (with multiple databases option)
and EBSCOhost databases. Additional sources were
5
Bonney W..
ENABLING FACTORS FOR ACHIEVING GREATER SUCCESS IN ELECTRONIC MEDICAL RECORD INITIATIVES.
DOI: 10.5220/0003686200050011
In Proceedings of the International Conference on Health Informatics (HEALTHINF-2012), pages 5-11
ISBN: 978-989-8425-88-1
Copyright
c
2012 SCITEPRESS (Science and Technology Publications, Lda.)
retrieved using the SAGE Journals Online,
ScienceDirect, Google Scholar, and ACM digital
libraries. The targeted search terms consisted of the
combination of keywords and/or phrases including:
(a) electronic medical record; (b) electronic medical
record AND success factors; (c) electronic medical
record AND success; and (d) electronic medical
record AND interoperability.
Overall, 467 articles were identified and 34 of
them were reviewed in full. Findings from the
reviewed papers are synthesized, paraphrased (in
some cases quoted) and categorized under four
broad themes: Overview of Electronic Medical
Record; Enabling Factors; Research and Practical
Implications; and Conclusion. Studies were included
in the analysis if they reported on successful factors
to implementing and using electronic medical
record.
3 OVERVIEW OF ELECTRONIC
MEDICAL RECORD (EHR)
Electronic Medical Record (EMR) may be defined
as a modern computerized medical information
system that collect, store, share, and display patient
information (Boonstra and Broekhuis, 2010; Brooks
and Grotz, 2010; Hsieh, 2010). EMR systems are the
newest form of documenting and storing pertinent
patient’s information including demographics,
medical history, allergies, diagnosis, procedures,
prescriptions, medications, laboratory results, and
insurance information (Brooks and Grotz, 2010;
Venkatraman et al., 2008). Beiter, Sorscher,
Henderson, and Talen (2008) emphasized on the
importance of EMR in the healthcare industry by
asserting that EMR systems are the future of primary
care.
EMR is not an Electronic Health Record (EHR),
which in itself is essentially a “repository of
information regarding the health status of a subject
of care in computer processable form, stored and
transmitted securely, and accessible by multiple
authorized users” (International Organization for
Standardization (ISO/TC 215), 2005, p. 2). The
EMR is, however, a special case of the EHR
restricted in scope to the medical domain (ISO/TC
215, 2005). EMR systems have the potential to
revolutionalize and transform healthcare delivery by
increasing efficiency of healthcare services; and
improving quality of care and patient satisfaction
(Al-Azmi et al., 2009; Beiter et al., 2008; Williams
and Boren, 2008).
The benefits of adopting EMR systems in the
healthcare domain are enormous (Jones & Kessler,
2010). The principal benefits for using EMR
systems are their capabilities to increase adherence
to clinical practice guidelines; enhance surveillance
and monitoring; facilitate clinical decision-making
process; decrease medication errors; reduce paper,
printing and transcribing costs; improve availability
of charts, improve co-ordination of care; increase
legibility of clinical data; and improve quality of
care, safety, and patient education (Beiter et al.,
2008; Jones and Kessler, 2010; Linz and Fallon Jr.,
2008; Shachak et al., 2009; Williams and Boren,
2008). Despite its enormous benefits, many
healthcare organizations have been slow to adopt the
EMR technology (Jones and Kessler, 2010; McGrath
et al., 2007). This is partly due to several factors that
act as barriers to the successful implementation of
EMR initiatives.
4 ENABLING FACTORS
In a case study conducted to explore factors that
have continuously influenced the successful
implementation of EMR systems, Gagnon et al.
(2010) identified six key enabling factors to be
critical: individual factors; professional factors;
organizational factors; contextual, political, and
financial factors; legal factors; and technological
factors. The following sections describe how these
six factors, proposed by Gagnon et al. (2010), can be
applied effectively and successfully to EMR
initiatives.
4.1 Individual Factors
Gagnon et al. (2010) identified individual factors to
comprise of both personal characteristics and
attitudes of healthcare providers. According to
Gagnon et al. (2010), identifying individuals within
an organization who exhibit unique characteristics
and greater openness to technology adoption will
serve as an agent of change. Klehr, Hafner, Spelz,
Steen, and Weaver (2009) echoed similar assessment
by noting that one of the key factors to
implementing successful EMR systems involves
close collaboration amongst individual staff
members and information technology staff with
close support from the project leader.
Drawing upon the ethnographic study by Ventres
et al. (2006), Beiter et al. (2008) noted that patients’
attitudes and comfort with computers influenced
their beliefs and concerns about the use of EMR
HEALTHINF 2012 - International Conference on Health Informatics
6
systems. Clinicians and other healthcare
practitioners’ openness to change and familiarity
with informatics may play a crucial role in
explaining variability in adoption between
individuals within the same profession (Gagnon et
al., 2010). The implementation of EMR systems
may be resisted if users are deficient in computer
skills and are not satisfied with the system design
(Al-Azmi et al., 2009; Van Der Meijden et al.,
2003). However, professionals in the healthcare
industry who are knowledgeable about computers
and open to change will embrace the adoption of
EMR systems without much resistance.
4.2 Professional Factors
The professional factors focus on the workload,
workflow, and teamwork processes in a local
clinical setting (Gagnon et al., 2010). Many
clinicians work in a time-constrained environment
with heavy schedule and frequent interruptions.
EMR systems are, therefore, used by time-pressured
and frequently interrupted healthcare providers,
many of whose workflows are too idiosyncratic for
effective automation (Walker, 2005). Thus, fostering
the adoption of EMR initiatives requires the
development of healthcare information systems that
is enabling and not constraining to the workflow of
clinicians.
For the EMR systems to be truly useful and
successful, Clarke, Hartswood, Procter, and
Rouncefield (2001) and Hoffmann (2009) noted that
the technology and work practices must be able to
co-evolve and fit seamlessly into clinicians’ routine
workflow. Specifically, Clarke et al. (2001) noted
that “IT design and development methodologies
must support user-led change processes, adapting the
technology to meet users’ needs as these emerge
through use” (p. 170). It is therefore very important
that EMR systems are strategically aligned with
clinical and administrative processes (Venkatraman
et al., 2008).
4.3 Organizational Factors
The premise of organizational factors focuses on
leadership and a presence of a champion (Gagnon et
al., 2010). Successful implementation of EMR
initiatives will require a leader who will champion
the development of EMR systems. Canada Health
Infoway (2011) suggested the need for the project
leader and/or champion to take charge in the
implementation of EMR systems. Gagnon et al.
(2010) found that active involvement of the project
champion in system design, coupled with on-site
technical support to all users were the solutions put
forward to help overcome most of the obstacles
facing the adoption of EMR systems in clinical
settings.
Organizations pursuing EMR initiatives should
have in place an availability of evidence-based
implementation strategy. Klehr et al. (2009)
emphasized on the need to use readily available
expert resources. These expert resources should be
researched, well-thought, and developed by the
project leader/champion before the initiation of the
EMR project. Gagnon et al. (2010) found that the
existence of a planned strategy based on the
literature on Information and Communication
Technology (ICT) adoption played an important role
in the implementation of EMR systems.
The organization’s innovation culture and
openness to change is also very critical in
influencing the success of EMR initiatives.
According to Gagnon et al (2010), “the state of
organisational readiness for change not only affects
the computerisation of the medical record, but also
everything that it involves in terms of changes” (p.
36). Boonstra and Broekhuis (2010) reaffirmed that
the success of EMR initiatives depends on the
quality of change management and thus the process
of implementing EMR initiatives should be treated
as change management projects and led by
implementers and/or change managers
knowledgeable in medical practices.
4.4 Contextual, Political, and Financial
Factors
The context in which the EMR initiative is
undertaken is very important in establishing success.
Introducing the EMR technology into “complex
work and organizational settings are often
unpredictable, and can only be determined in the
context of use” (Clarke et al., 2001, p. 170). There
exist differences in how the implementation of the
EMR technology is embraced in the rural setting
versus urban settings. Al-Azmi et al. (2009) and
Williams and Boren (2008) also identified
differences on how they are embraced in developed
versus developing countries. Acknowledging the
fact that most developed countries implement EMR
systems because of its associated benefits, Williams
and Boren (2008) noted that the transition from the
traditional paper-based system to EMR systems
often brings some level of fear and resistance to
change in the developing countries. These
ENABLING FACTORS FOR ACHIEVING GREATER SUCCESS IN ELECTRONIC MEDICAL RECORD
INITIATIVES
7
perceptions have undermined the widespread
adoption of EMR systems in the healthcare industry.
The political will to invest in EMR initiatives is
essential in achieving success in their
implementation (Jones and Kessler, 2010). The
government readiness and willingness in supporting
EMR initiative is always helpful in launching the
project in a given national setting or climate
(Gagnon et al., 2010). For example, in a study
conducted in Taiwan to identify factors that affect
hospitals’ willingness to implement EMR initiatives,
Chang, Hwang, Hung, Kuo, and Yen (2009) found
that perceived benefits, uncertainty, influence and
reciprocal investments had significant impact on the
decision to implement EMR initiatives.
The success of EMR initiatives also depend on
the availability of funding (Brooks and Grotz, 2010;
Callan and DeShazo, 2007; Canada Health Infoway,
2011; Cavolo, 2007; Gagnon et al., 2010; Kumar
and Aldrich, 2010). Brooks and Grotz (2010) even
made it clearer by noting that funding is the largest
setback to implementing EMR initiatives. The use of
health information systems and their associated
technical support all require significant financial
investment and ongoing maintenance. Gagnon et al.
(2010) emphasized on the importance of financial
investment by noting that implementing EMR
systems require additional costs in terms of
equipment, contracts and human resources. Such
additional costs may include restructuring workflow
in clinical settings; knowledge transfer to
employees; and in-house IT support and training
(Beiter et al., 2008; O'Neill and Klepack, 2007).
Inadequate training of personnel is a disaster for
EMR adoption (Callan and DeShazo, 2007).
Williams and Boren (2008) considered in-house
training of healthcare providers as one of the key
elements to the success of EMR initiatives.
4.5 Legal Factors
The healthcare industry is plagued with legal actions
when it comes to the accessibility of personalized
health information contained in an electronic format.
According to Myers, Frieden, Bherwani, and
Henning (2008), the availability of personalized
health information in electronic format threatens the
integrity, confidentiality, security and privacy of
health data. Unauthorized access to these
personalized data often leads to liabilities that
require proper security protocols and management
from the part of the healthcare provider.
Successful implementation and adoption of EMR
systems has been slow and a long process because of
privacy and confidentiality policies surrounding the
use of the system (Brooks & Grotz, 2010). The
United States Congress enacted the Health Insurance
Portability and Accountability Act (HIPAA) in 1996
with the goal of setting up regulations to standardize
the collection, storage, and dissemination of
personalized health information (Brooks and Grotz,
2010; Harrison and Ramanujan, 2011; Hoffmann,
2009). However, the implementation of these
regulations regarding the secure exchange of clinical
information between the various EMR users across
settings of care is not an easy endeavour and still
represents a complex issue (Gagnon et al., 2010, p.
37). Brooks and Grotz (2010) also made similar
assessment by noting that “it is commonly
acknowledged that the regulation is insufficient to
cover the new and swiftly developing e-health
environment presented as a result of the EMR
system” (p, 76). For example, HIPAA does not
address data ownership (Hoffmann, 2009).
Williams and Boren (2008) therefore
recommended the need for the development of
privacy, confidentiality, and security principles to
protect patients’ interests against inappropriate
access to their personalized health data. The
introduction of proper IT Governance framework
that establishes control and accountability of health
data will also be fruitful in protecting the integrity of
personalized health information. Kahn, Aulakh, and
Bosworth (2009) correctly noted that widespread
consumer acceptance and adoption of healthcare
information systems is not possible until all issues
relating to data security, identity protection, and
consumer satisfactions are resolved by dedicated
national bodies.
4.6 Technological Factors
There are uncertainties or disagreements amongst
healthcare IT professionals on the appropriate core
components of EMR systems (Hsieh, 2010). Hseih
(2010) argued that most of the core components of
EMR systems have typically been drawn from
marketing campaigns of products rather than from
standard specifications. Establishing appropriate
core components of EMR systems requires
technologies that utilize health data standards and
interoperability.
4.6.1 Health Data Standards
Health data standards are critical for developing the
core components of the EMR system. The standards
need to explicitly specify how data is presented,
HEALTHINF 2012 - International Conference on Health Informatics
8
captured, stored, and conveyed (W. Hammond,
Bailey et al., 2010). The idea of using health data
standards is to enable disparate EMR systems to
exchange clinical information in an integrated
healthcare environment, thereby, facilitating greater
integration and cohesion of healthcare services
(Clarke et al., 2001). The health data standards
should support the collection, storage, exchange, and
retrieval of electronic medical information for the
EMR system (Hoffmann, 2009).
Similarly, W. E. Hammond (2005) claimed that
health data standards are needed in order to create
aggregated, patient-centric EMR systems. W. E.
Hammond (2005) went further and recommended
the need for the “creation of a neutral, nonprofit
organization in the private sector with the authority
to manage all aspects of health data standards” (p.
1213). According to Venkatraman et al. (2008), the
use of clinical data exchange standards in EMR
systems is one of the key strategies in ensuring that
EMR systems deliver business value to the
healthcare IT community. The availability of health
data standards is very useful in supporting the
interoperability of EMR systems.
4.6.2 Interoperability
Interoperability is one of the main enabling
technologies for the utilization of EMR in integrated
healthcare information systems. W. Hammond et al.
(2010) defined interoperability as the “ability to
communicate and exchange data accurately among
different IT systems, software applications, and
networks” (p. 284). The interoperability concept is
divided into three distinct levels of functionality:
interface engine, functional interoperability, and
semantic interoperability (Freedman, 2007; ISO/TC
215, 2005).
Acknowledging the fact that semantic
interoperability is the most sophisticated form of
interoperability, Freedman (2007) indicated that
semantic interoperability “allows two systems not
only to share information, it also enables the
receiving system to understand and make use of the
incoming data while maintaining the original
meaning of that data” (p. 50). These functionalities
of interoperability have facilitated the development
of classification and terminology standards that are
currently used in the development of EMR systems.
W. Hammond et al. (2010) noted that
interoperability cannot be achieved without the
existence of health data standards that are agreed
upon by dedicated national bodies.
5 PRATICAL AND RESEARCH
IMPLICATIONS
The benefits of using EMR systems in medical
practice are numerous. The use of EMR systems will
enable physicians at the point of care to provide
evidence-based medicine and improve the efficiency
of healthcare delivery. Healthcare providers are
capable of influencing the implementation of
effective EMR systems if they are passionately
committed to transforming the ways they provide
care for patients (Walker, 2005). Improvement in
clinical outcomes depends heavily on the successful
implementation and adoption of EMR systems
(Diamond & Shirky, 2008).
Using a phase implementation approach will
ensure that all the critical success factors identified
in the paper are applied appropriately to EMR
initiatives. Walker (2005) noted that an “EMR
implementation that is capable of supporting less
error-prone care processes will require substantial
resources for workflow analysis, software
configuration, testing, and user training” (p, 1118).
There is a general consensus among many
researchers that successful implementation of EMR
initiatives will require good planning, strong
management and physician leadership, supportive
staff, and ongoing IT support (Gagnon et al., 2010;
Williams and Boren, 2008).
Establishing semantic interoperability in EMR
systems is one of the critical factors in ensuring that
EMR initiatives are successful with less failure. The
lack of standards and structured data definitions for
EMR systems contributes to the difficult in
achieving interoperability in many existing EMR
systems (Kumar & Aldrich, 2010). Hence,
developing an integrated IT architecture and
infrastructure to support EMR systems will enable
hospitals to get better results and provide high
quality services to patients.
Achieving successful implementation of EMR
initiatives will also require some trade-offs.
Acknowledging the fact that there exists a trade-off
between achieving rapid implementation of EMR
technology and strong healthcare privacy laws,
Brooks and Grotz (2010) noted that while healthcare
privacy laws remain positive for healthcare
consumers, it does not always allow for quick EMR
systems implementation. Accommodating this trade-
off will involve finding the right balance between
standardization and flexibility. Whereas
standardization ensures interoperability and secure
exchange of clinical information, flexibility
accommodates the various systems and architectures
ENABLING FACTORS FOR ACHIEVING GREATER SUCCESS IN ELECTRONIC MEDICAL RECORD
INITIATIVES
9
that different healthcare providers need (Hoffmann,
2009).
6 CONCLUSIONS
This paper has explored the possible trends or
factors which may help future EMR initiatives
achieve greater success and less failure. Healthcare
providers are encouraged to develop strategic
initiatives to influence the successful adoption of
EMR systems. There is an expectation that low
implementation cost and making the technology
appealing to physicians will stimulate and accelerate
the adoption of EMR initiatives in medical practice
(Bristol, 2005). Although several challenges are
facing the adoption of EMR in medical practice,
there is strong evidence from the literature that when
properly developed and deployed, EMR systems will
benefit the healthcare community in establishing
efficient and quality healthcare delivery and
evidence-based practice (Al-Azmi et al., 2009;
Beiter et al., 2008; Williams and Boren, 2008).
EMR systems continue to remain attractive to
many healthcare providers. However, the cost of
ownership cannot be ignored (Callan and DeShazo,
2007; Cavolo, 2007; Kumar and Aldrich, 2010;
O'Neill and Klepack, 2007; Venkatraman et al.,
2008). The cost of owning EMR systems does not
come with other needed day-to-day operational
maintenances and upgrade to the systems as well as
technical support. With the looming cost of
ownership of the EMR systems, many researchers
have recommended the need for the availability of
evidence-based implementation strategy to guide
project leaders (Chang et al., 2009; Gagnon et al.,
2010). Gagnon et al. (2010) found that the
involvement of project leaders in systems design, as
well as on-site technical support to all users are very
critical in helping overcome the obstacles facing the
adoption and implementation of EMR initiatives.
Change management also plays an important role
in the successful implementation of EMR initiatives
(Boonstra and Broekhuis, 2010). The development
of appropriate and strategic change management
processes in healthcare organizations could be an
incentive to accelerate the adoption in EMR systems
in medical practice. Healthcare providers and policy
makers can promote EMR initiatives by identifying
desirable stakeholders and partners that will form a
strategic alliance to meet the dynamic challenges in
the healthcare industry (Chang et al., 2009; Clarke et
al., 2001). Future research should therefore focus on
developing an appropriate IT governance structure
or framework that will guide project leaders in
championing the successful implementation of EMR
initiatives.
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ENABLING FACTORS FOR ACHIEVING GREATER SUCCESS IN ELECTRONIC MEDICAL RECORD
INITIATIVES
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