literature review on electronic health records

• Research article
• Open access
• Published: 04 September 2014

Implementing electronic health records in hospitals: a systematic literature review

• Albert Boonstra 1 ,
• Arie Versluis 2 &
• Janita F J Vos 1  

BMC Health Services Research volume  14 , Article number:  370 ( 2014 ) Cite this article

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The literature on implementing Electronic Health Records (EHR) in hospitals is very diverse. The objective of this study is to create an overview of the existing literature on EHR implementation in hospitals and to identify generally applicable findings and lessons for implementers.

A systematic literature review of empirical research on EHR implementation was conducted. Databases used included Web of Knowledge, EBSCO, and Cochrane Library. Relevant references in the selected articles were also analyzed. Search terms included Electronic Health Record (and synonyms), implementation, and hospital (and synonyms). Articles had to meet the following requirements: (1) written in English, (2) full text available online, (3) based on primary empirical data, (4) focused on hospital-wide EHR implementation, and (5) satisfying established quality criteria.

Of the 364 initially identified articles, this study analyzes the 21 articles that met the requirements. From these articles, 19 interventions were identified that are generally applicable and these were placed in a framework consisting of the following three interacting dimensions: (1) EHR context, (2) EHR content, and (3) EHR implementation process.

Conclusions

Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. This systematic review reveals reasons for this complexity and presents a framework of 19 interventions that can help overcome typical problems in EHR implementation. This framework can function as a reference for implementers in developing effective EHR implementation strategies for hospitals.

Peer Review reports

In recent years, Electronic Health Records (EHRs) have been implemented by an ever increasing number of hospitals around the world. There have, for example, been initiatives, often driven by government regulations or financial stimulations, in the USA [ 1 ], the United Kingdom [ 2 ] and Denmark [ 3 ]. EHR implementation initiatives tend to be driven by the promise of enhanced integration and availability of patient data [ 4 ], by the need to improve efficiency and cost-effectiveness [ 5 ], by a changing doctor-patient relationship toward one where care is shared by a team of health care professionals [ 5 ], and/or by the need to deal with a more complex and rapidly changing environment [ 6 ].

EHR systems have various forms, and the term can relate to a broad range of electronic information systems used in health care. EHR systems can be used in individual organizations, as interoperating systems in affiliated health care units, on a regional level, or nationwide [ 1 , 2 ]. Health care units that use EHRs include hospitals, pharmacies, general practitioner surgeries, and other health care providers [ 7 ].

The implementation of hospital-wide EHR systems is a complex matter involving a range of organizational and technical factors including human skills, organizational structure, culture, technical infrastructure, financial resources, and coordination [ 8 , 9 ]. As Grimson et al. [ 5 ] argue, implementing information systems (IS) in hospitals is more challenging than elsewhere 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 [ 10 ] provide three reasons why hospitals differ from many other industries, and these differences might also affect EHR implementations. The first reason is that hospitals have multiple objectives, such as curing and caring for patients, and educating new physicians and nurses. Second, hospitals have complicated and highly varied structures and processes. Third, hospitals have a varied workforce including medical professionals who possess high levels of expertise, power, and autonomy. These distinct characteristics justify a study that focuses on the identification and analysis of the findings of previous studies on EHR implementation in hospitals.

Study aim, theoretical framework, and terminology

In dealing with the complexity of EHR implementation in hospitals, it is helpful to know which factors are seen as important in the literature and to capture the existing knowledge on EHR implementation in hospitals. As such, the objective of this research is to identify, categorize, and analyze the existing findings in the literature on EHR implementation processes in hospitals. This could contribute to greater insight into the underlying patterns and complex relationships involved in EHR implementation and could identify ways to tackle EHR implementation problems. In other words, this study focusses on the identification of factors that determine the progress of EHR implementation in hospitals. The motives behind implementing EHRs in hospitals and the effects on performance of implemented EHR systems are beyond the scope of this paper.

To our knowledge, there have been no systematic reviews of the literature concerning EHR implementation in hospitals and this article therefore fills that gap. Two interesting related review studies on EHR implementation are Keshavjee et al. [ 11 ] and McGinn et al. [ 12 ]. The study of Keshavjee et al. [ 11 ] develops a literature based integrative framework for EHR implementation. McGinn et al. [ 12 ] adopt an exclusive user perspective on EHR and their study is limited to Canada and countries with comparable socio-economic levels. Both studies are not explicitly focused on hospitals and include other contexts such as small clinics and national or regional EHR initiatives.

This systematic review is explicitly focused on hospital-wide, single hospital EHR implementations and identifies empirical studies (that include collected primary data) that reflect this situation. The categorization of the findings from the selected articles draws on Pettigrew’s framework for understanding strategic change [ 13 ]. This model has been widely applied in case study research into organizational contexts [ 14 ], as well as in studies on the implementation of health care innovations [ 15 ]. It generates insights by analyzing three interactive dimensions – context , content , and process – that together shape organizational change. Pettigrew’s framework [ 13 ] is seen as applicable because implementing an EHR artefact is an organization-wide effort. This framework was specifically selected for its focus on organizational change, its ease of understanding, and its relatively general dimensions allowing a broad range of findings to be included. The framework structures and focusses the analysis of the findings from the selected articles.

An organization’s context can be divided into internal and external components. External context refers to the social, economic, political, and competitive environments in which an organization operates. The internal context refers to the structure, culture, resources, capabilities, and politics of an organization. The content covers the specific areas of the transformation under examination. In an EHR implementation, these are the EHR system itself (both hardware and software), the work processes, and everything related to these (e.g. social conditions). The process dimension concerns the processes of change, made up of the plans, actions, reactions, and interactions of the stakeholders, rather than work processes in general. It is important to note that Pettigrew [ 13 ] does not see strategic change as a rational analytical process but rather as an iterative, continuous, multilevel process. This highlights that the outcome of an organizational change will be determined by the context, content, and process of that change. The framework with its three categories, shown in Figure  1 , illustrates the conceptual model used to categorize the findings of this systematic literature review.

Pettigrew ’ s framework [ 13 ] ] and the corresponding categories.

In the literature, several terms are used to refer to electronic medical information systems. In this article, the term Electronic Health Record (EHR) is used throughout. Commonly used terms identified by ISO (the International Organization for Standardization) [ 16 ] plus another not identified by ISO are outlined below and used in our search. ISO considers Electronic Health Record (EHR) to be an overall term for “ a repository of information regarding the health status of a subject of care , in computer processable form ” [ 16 ], p. 13. ISO uses different terms to describe various types of EHRs. These include Electronic Medical Record (EMR), which is similar to an EHR but restricted to the medical domain. The terms Electronic Patient Record (EPR) and Computerized Patient Record (CPR) are also identified. Häyrinen et al. [ 17 ] view both terms as having the same meaning and referring to a system that contains clinical information from a particular hospital. Another term seen is Electronic Healthcare Record (EHCR) which refers to a system that contains all the available health information on a patient [ 17 ] and can thus be seen as synonymous with EHR [ 16 ]. A term often found in the literature is Computerized Physician Order Entry (CPOE). Although this term is not mentioned by ISO [ 16 ] or by Häyrinen et al. [ 17 ], we included CPOE for three reasons. First, it is considered by many to be a key hospital-wide function of an EHR system e.g. [ 8 , 18 ]. Second, from a preliminary analysis of our initial results, we found that, from the perspective of the implementation process, comparable issues and factors emerged from both CPOEs and EHRs. Third, the implementation of a comprehensive electronic medical record requires physicians to make direct order entries [ 19 ]. Kaushal et al. define a CPOE as “ 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 ” [ 18 ], p. 1410. Other terms found in the literature were not included in this review as they were considered either irrelevant or too broadly defined. Examples of such terms are Electronic Client Record (ECR), Personal Health Record (PHR), Digital Medical Record (DMR), Health Information Technology (HIT), and Clinical Information System (CIS).

Search strategies

In order for a systematic literature review to be comprehensive, it is essential that all terms relevant to the aim of the research are covered in the search. Further, we need to include relevant synonyms and related terms, both for electronic medical information systems and for hospitals. By adding an * to the end of a term, the search engines pick out other forms, and by adding “ “ around words one ensures that only the complete term is searched for. Further, by including a ? as a wildcard character, every possible combination is included in the search.

The search used three categories of keywords. The first category included the following terms as approximate synonyms for hospital: “hospital*”, “healthcare”, and “clinic*”. The second category concerned implementation and included the term “implement*”. For the third category, electronic medical information systems, the following search terms were used: “Electronic Health Record*”, “Electronic Patient Record*”, “Electronic Medical Record*”, “Computeri?ed Patient Record*”, “Electronic Healthcare Record*”, “Computeri?ed Physician Order Entry”.

This relatively large set of keywords was necessary to ensure that articles were not missed in the search, and required a large number of search strategies to cover all those keywords. As we were seeking papers about the implementation of electronic medical information systems in hospitals , the search strategies included the terms shown in Table  1 .

The following three search engines were chosen based on their relevance to the field and their accessibility by the researcher: Web of knowledge, EBSCO, and The Cochrane Library. Most search engines use several databases but not all of them were relevant for this research as they serve a wide range of fields. Appendix A provides an overview of the databases used. The reference lists included in articles that met the selection criteria were checked for other possibly relevant studies that had not been identified in the database search.

The articles identified from the various search strategies had to be academic peer-reviewed articles if they were to be included in our review. Further, they were assessed and had to satisfy the following criteria to be included: (1) written in English, (2) full text available online, (3) based on primary empirical data, (4) focused on hospital-wide EHR implementation, and (5) meeting established quality criteria. A long list of abstracts was generated, and all of them were independently reviewed by two of the authors. They independently reviewed the abstracts, eliminated duplicates and shortlisted abstracts for detailed review. When opinions differed, a final decision over inclusion was made following a discussion between the researchers.

Data analysis

The quality of the articles that survived this filtering was assessed by the first two authors using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers [ 18 ]. In other words, the quality of the articles was jointly assessed by evaluating whether specific criteria had been addressed, resulting in a rating of 2 (fully addressed), 1 (partly addressed), or 0 (not addressed) for each criteria. Different questions are posed for qualitative and quantitative research and, in the event of a mixed-method study, both questionnaires were used. Papers were included if they received at least half of the total possible points, admittedly a relatively liberal cut-off point given comments in the Standard Quality Assessment Criteria for Evaluating Primary Research Papers [ 20 ].

The next step was to extract the findings of the reviewed articles and to analyze these with the aim of reaching general findings on the implementation of EHR systems in hospitals. Categorizing these general findings can increase clarity. The earlier introduced conceptual model, based on Pettigrew’s framework for understanding strategic change, includes three categories: context (A), content (B), and process (C). As our review is specifically aimed at identifying findings related to the implementation process, possible motives for introducing such a system, as well as its effects and outcomes, are outside its scope. The authors held frequent discussions between themselves to discuss the meaning and the categorization of the general findings.

Paper selection

Applying the 18 search strategies listed in Table  1 with the various search engines resulted in 364 articles being identified. The searches were carried out on 12 March 2013 for search strategies 1–15 and on 18 April 2013 for search strategies 16–18. The latter three strategies were added following a preliminary analysis of the first set of results which highlighted several other terms and descriptions for information technology in health care. Not surprisingly, many duplicates were included in the 364 articles, both within and between search engines. Using the Refworks functions for identifying exact and close duplicates, 160 duplicates were found. However, this procedure did not identify all the duplicates present and the second author carried out a manual check that identified an additional 23 duplicates. When removing duplicates, we retained the link to the first search engine that identified the article and, as the Web of Knowledge was the first search engine used, most articles appear to have stemmed from this search engine. This left 181 different articles which were screened on title and abstract to check whether they met the selection criteria. When this was uncertain, the contents of the paper were further investigated. This screening resulted in just 13 articles that met all the selection criteria. We then performed two additional checks for completeness. First, checking the references of these articles identified another nine articles. Second, as suggested by the referees of this paper, we also used the term “introduc*” instead of “implement*”, together with the other two original categories of terms, and the term “provider” instead of “physician”, as part of CPOE. Each of these two searches identified one additional article (see Table  1 ). Of these resulting 24 articles, two proved to be almost identical so one was excluded, resulting in 23 articles for a final quality assessment.The results of the quality assessment can be found in Appendix B. The results show that two articles failed to meet the quality threshold and so 21 articles remained for in-depth analysis. Figure  2 displays the steps taken in this selection procedure.

Selection procedure.

To provide greater insight into the context and nature of the 21 remaining articles, an overview is provided in Table  2 . All the studies except one were published after 2000. This reflects the recent increase in effort to implement organization-wide information systems, such as EHR systems, and also increasing incentives from governments to make use of EHR systems in hospitals. Of the 21 studies, 14 can be classified as qualitative, 6 as quantitative, and 1 as a mixed-method study. Most studies were conducted in the USA, with eight in various European countries. Teaching and non-teaching hospitals are almost equally the subject of inquiry, and some researchers have focused on specific types of hospitals such as rural, critical access, or psychiatric hospitals. Ten of the articles were in journals with a five-year impact factor in the Journal Citation Reports 2011 database. There is a huge difference in the number of citations but one should never forget that newer studies have had fewer opportunities to be cited.

Theoretical perspectives of reviewed articles

In research, it is common to use theoretical frameworks when designing an academic study [ 41 ]. 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 [ 42 ]. By building on existing theories, research becomes focused in aiming to enrich and extend the existing knowledge in that particular field [ 42 ]. To provide a more thorough understanding of the selected articles, their theoretical frameworks, if present, are outlined in Table  3 .

It is striking that no specific theoretical frameworks have been used in the research leading to 13 of the 21 selected articles. Most articles simply state their objective as gaining insight into certain aspects of EHR implementation (as shown in Table  1 ) and do not use a particular theoretical approach to identify and categorize findings. As such, these articles add knowledge to the field of EHR implementation but do not attempt to extend existing theories.

Aarts et al. [ 21 ] introduce the notion of the sociotechnical approach: emphasizing the importance of focusing both on the social aspects of an EHR implementation and on the technical aspects of the system. Using the concept of emergent change, they argue that an implementation process is far from linear and predictable due to the contingencies and the organizational complexity that influences the process. A sociotechnical approach and the concept of emergent change are also included in the theoretical framework of Takian et al. [ 37 ]. Aarts et al. [ 21 ] elaborate on the sociotechnical approach when stating that the fit between work processes and the information technology determines the success of the implementation. Aarts and Berg [ 22 ] introduce a model of success or failure in information system implementation. They see creating synergy among the medical work practices, the information system, and the hospital organization as necessary for implementation, and argue that this will only happen if sufficient people accept a change in work practices. Cresswell et al.’s study [ 26 ] is also influenced by sociotechnical principles and draws on Actor-Network Theory. Gastaldi et al. [ 28 ] perceive Electronic Health Records as knowledge management systems and question how such systems can be used to develop knowledge assets. Katsma et al. [ 31 ] focus on implementation success and elaborate on the notion that implementation success is determined by system quality and acceptance through participation. As such, they adopt more of a social view on implementation success rather than a sociotechnical approach. Rivard et al. [ 34 ] examine the difficulties in EHR implementation from a cultural perspective. They not only view culture as a set of assumptions shared by an entire collective (an integration perspective) but also expect subcultures to exist (a differentiation perspective), as well as individual assumptions not shared by a specific (sub-) group (fragmentation perspective). Ford et al. [ 27 ] focus on an entirely different topic and investigate the IT adoption strategies of hospitals using a framework that identifies three strategies. These are the single-vendor strategy (in which all IT is purchased from a single vendor), the best-of-breed strategy (integrating IT from multiple vendors), and the best-of-suit strategy (a hybrid approach using a focal system from one vendor as the basis plus other applications from other vendors).

To summarize, the articles by Aarts et al. [ 21 ], Aarts and Berg [ 22 ], Cresswell et al. [ 26 ], and Takian et al. [ 37 ] apply a sociotechnical framework to focus their research. Gastaldi et al. [ 28 ] see EHRs as a means to renew organizational capabilities. Katsma et al. [ 31 ] use a social framework by focusing on the relevance of an IT system as perceived by the user and the participation of users in the implementation process. Rivard et al. [ 34 ] analyze how organizational cultures can be receptive to EHR implementation. Ford et al. [ 27 ] look at adoption strategies, leading them to focus on the selection procedure for Electronic Health Records. The 13 other studies did not use an explicit theoretical lens in their research.

Implementation-related findings

The process of categorization started by assessing whether a specific finding from a study should be placed in Category A, B, or C. Thirty findings were placed in Category A (context), 31 in Category B (content), and 66 in Category C (process). Comparing and combining the specific findings resulted in several general findings within each category. The general findings are each given a code (category character plus number) and the related code is indicated alongside each specific finding in Appendix C. Findings that were only seen in one article, and thus were lacking support, were discarded.

Category A - context

The context category of an EHR implementation process includes both internal variables (such as resources, capabilities, culture, and politics) and external variables (such as economic, political, and social variables). Six general findings were identified, all but one related to internal variables. An overview of the findings and corresponding articles can be found in Table  4 . The lack of general findings related to external variables reflects our decision to exclude the underlying reasons (e.g. political or social pressures) for implementing an EHR system from this review. Similarly, internal findings related to aspects such as perceived financial benefits or improved quality of care, are outside our scope.

A1: Large (or system-affiliated), urban, not-for-profit, and teaching hospitals are more likely to have implemented an EHR system due to having greater financial capabilities, a greater change readiness, and less focus on profit

The research reviewed shows that larger or system-affiliated hospitals are more likely to have implemented an EHR system, and that this can be explained by their easier access to the large financial resources required. Larger hospitals have more financial resources than smaller hospitals [ 30 ] and system-affiliated hospitals can share costs [ 27 ]. Hospitals situated in urban areas more often have an EHR system than rural hospitals, which is attributed to less knowledge of EHR systems and less support from medical staff in rural hospitals [ 29 ]. The fact that not-for-profit hospitals more often have an EHR system fully implemented and teaching hospitals slightly more often than private hospitals is attributed to the latter’s more wait-and-see approach and the more progressive change-ready nature of public and teaching hospitals [ 27 , 32 ].

A2: EHR implementation requires the selection of a mature vendor who is committed to providing a system that fits the hospital’s specific needs

Although this finding is not a great surprise, it is relevant to discuss it further. A hospital selecting its own vendor can ensure that the system will match the specific needs of that hospital [ 32 ]. Further, it is important to deal with a vendor that has proven itself on the EHR market with mature and successful products. The vendor must also be able to identify hospital workflows and adapt its product accordingly, and be committed to a long-term trusting relationship with the hospital [ 33 ]. With this in mind, the initial price of the system should not be the overriding consideration: the organization should be willing to avoid purely cost-oriented vendors [ 28 ], as costs soon mount if problems arise.

A3: The presence of hospital staff with previous experience of health information technology increases the likelihood of EHR implementation as less uncertainty is experienced by the end-users

In order to be able to work with an EHR system, users must be capable of using information technology such as computers and have adequate typing skills [ 19 , 32 ]. Knowledge of, and previous experience with, EHR systems or other medical information systems reduces uncertainty and disturbance for users, and this results in a more positive attitude towards the system [ 29 , 32 , 37 , 38 ].

A4: An organizational culture that supports collaboration and teamwork fosters EHR implementation success because trust between employees is higher

The influence of organizational culture on the success of organizational change is addressed in almost all the popular approaches to change management, as well as in several of the articles in this literature review. Ash et al. [ 23 , 24 ] and Scott et al. [ 35 ] highlight that a strong culture with a history of collaboration, teamwork, and trust between different stakeholder groups minimizes resistance to change. Boyer et al. [ 25 ] suggest creating a favorable culture that is more adaptive to EHR implementation. However, creating a favorable culture is not necessarily easy: a comprehensive approach including incentives, resource allocation, and a responsible team was used in the example of Boyer et al. [ 25 ].

A5: EHR implementation is most likely in an organization with little bureaucracy and considerable flexibility as changes can be rapidly made

A highly bureaucratic organizational structure hampers change: it slows the process and often leads to inter-departmental conflict [ 19 ]. Specifically, appointing a multidisciplinary team to deal with EHR-related issues can prevent conflict and stimulate collaboration [ 25 ].

A6: EHR system implementation is difficult because cure and care activities must be ensured at all times

During the process of implementing an EHR system, it is of the utmost importance that all relevant information is always available [ 28 , 34 , 39 ]. Ensuring the continuity of quality care while implementing an EHR system is difficult and is an important distinction from many other IT implementations.

Category B - content

The content of the EHR implementation process consists of the EHR system and the corresponding objectives, assumptions, and complementary services. Table  5 lists the five extracted general findings. These focus on both the hardware and software of the EHR system, and its relation to work practices and privacy.

B1: Creating a fit by adapting both the technology and work practices is a key factor in the implementation of EHR

This finding elaborates on the sociotechnical approach identified in the earlier section on the theories adopted in the articles. Several authors [ 21 , 26 , 31 , 37 ] make clear that creating a fit between the EHR system and the existing work practices requires an initial acknowledgement that an EHR implementation is not just a technical project and that existing work practices will change due to the new system. By customizing and adapting the system to meet specific needs, users will become more open to using it [ 19 , 26 , 28 ].

B2: Hardware availability and system reliability, in terms of speed, availability, and a lack of failures, are necessary to ensure EHR use

In several articles, authors highlight the importance of having sufficient hardware. A system can only be used if it is available to the users, and a system will only be used if it works without problems. Ash et al. [ 24 ], Scott et al. [ 35 ], and Weir et al. [ 19 ] refer to the speed of the system as well as to the availability of a sufficient number of adequate terminals see also [ 40 ] in various locations. Systems must be logically structured [ 29 ], reliable [ 32 ], and provide safe information access [ 37 ]. Boyer et al. [ 25 ] also mention the importance of technical aspects but add that these are not sufficient for EHR implementation.

B3: To ensure EHR implementation, the software needs to be user-friendly with regard to ease of use, efficiency in use, and functionality

Some authors distinguish between technical availability and reliability, and the user-friendliness of the software [ 19 , 24 , 32 ]. They argue that it is not sufficient for a system to be available and reliable, it should also be easy and efficient in use, and provide the functionality required for medical staff to give good care. If a system fails to do this, staff will not use the system and will stick to their old ways of working.

B4: An EHR implementation should contain adequate safeguards for patient privacy and confidentiality

Concerns over privacy and confidentiality are recognized by Boyer et al. [ 25 ] and Houser and Johnson [ 29 ] and are considered as a barrier to EHR implementation. Yoon-Flannery et al. [ 40 ] and Takian et al. [ 37 ] also recognize the importance of patient privacy and the need to address this issue by providing training and creating adequate safeguards.

B5: EHR implementation requires a vendor who is willing to adapt its product to hospital work processes

A vendor must be responsive and enable the hospital to develop its product to ensure a good and usable EHR system [ 32 , 33 ]. By so doing, dependence on the vendor decreases and concerns that arise within the hospital can be addressed [ 32 ]. This finding is related to A2 in the sense that an experienced, cooperative, and flexible vendor is needed to deal with the range of interest groups found in hospitals.

Category C - process

This category refers to the actual process of implementing the EHR system. Variables considered are time, change approach, and change management. In our review, this category produced the largest number of general findings (see Table  6 ), as might be expected given our focus on the implementation process. EHR implementation often leads to anxiety, uncertainty, and concerns about a possible negative impact of the EHR on work processes and quality. The process findings, including leadership, resource availability, communication and participation are explicitly aimed at overcoming resistance to EHR implementation. These interventions help to create a positive atmosphere of goal directedness, co-creation and partnership.

C1: Due to their influential position, management’s active involvement and support is positively associated with EHR implementation, and also counterbalances the physicians’ medical dominance

Several authors note the important role that managers play in EHR implementation. Whereas some authors refer to supportive leadership [ 19 , 24 ], others emphasize that strong and active management involvement is needed [ 25 , 32 – 35 ]. Strong leadership is relevant as it effectively counterbalances the physicians’ medical dominance. For instance, Rivard et al. [ 34 ] observe that physicians’ medical dominance and the status and autonomy of other health professionals hinder collaboration and teamwork, and that this complicates EHR implementation. Poon et al. [ 33 ] acknowledge this aspect and argue for strong leadership in order to deal with the otherwise dominant physicians. They also claim that leaders have to set an example and use the system themselves. At the same time, it is motivating that the implementation is managed by leaders who are recognized by the medical staff, for instance by head nurses and physicians or by former physicians and nurses [ 25 , 33 ]. Ovretveit et al. [ 32 ] argue that it helps the implementation if senior management repeatedly declares the EHR implementation to be of the highest priority and supports this with sufficient financial and human resources. Poon et al. [ 33 ] add to this by highlighting that, especially during uncertainties and setbacks, the common vision that guides the EHR implementation has to be communicated to hospital staff. Sufficient human resources include the selection of competent and experienced project leaders who are familiar with EHR implementation. Scott et al. [ 35 ] identify leadership styles for different phases: participatory leadership is valued in selection decisions, whereas a more hierarchical leadership style is preferable in the actual implementation.

C2: Participation of clinical staff in the implementation process increases support for and acceptance of the EHR implementation

Participation of end-users (the clinical staff) generates commitment and enables problems to be quickly solved [ 25 , 26 , 36 ]. Especially because it is very unlikely that the system will be perfect for all, it is important that the clinical staff become the owner, rather than customers, of the system. Clinical staff should participate at all levels and in all steps [ 19 , 28 , 32 , 36 ] from initial system selection onwards [ 35 ]. Ovretveit et al. [ 32 ] propose that this involvement should have an extensive timeframe, starting in the early stages of implementation, when initial vendor requirements are formulated (‘consultation before implementation’), through to the beginning of the use phase. Creating multidisciplinary work groups which determine the content of the EHR and the rules regarding the sharing of information contributes to EHR acceptance [ 25 ] and ensures realistic approaches acceptable to the clinical staff [ 36 ].

C3: Training end-users and providing real-time support is important for EHR implementation success

Frequently, the end-users of a new EHR system lack experience with the specific EHR system or with EHR systems in general. Although it is increasingly hard to imagine society or workplaces without IT, a large specific system, such as an EHR, still requires considerable training on how to use it properly. The importance of training is often underestimated, and inadequate training will create a barrier to EHR use [ 19 , 29 ]. Consequently, adequate training, of appropriate quantity and quality, must be provided at the right times and locations [ 19 , 32 , 36 ]. Simon et al. [ 36 ] add to this the importance of real-time support, preferably provided by peers and super-users.

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

Several articles highlight aspects of an EHR implementation strategy. A good strategy facilitates EHR implementation [ 19 , 25 ] and consists of careful planning and preparation [ 36 ], a sustainable business plan, effective communication [ 28 , 40 ] and mandatory implementation [ 19 ]. Emergent change is perceived as a key characteristic of EHR implementation in complex organizations such as hospitals [ 21 ], and this suggests an implementation approach based on a development paradigm [ 31 ], which may initially even involve parallel use of paper [ 26 ]. The notion of emergent change has been variously applied, including in the theoretical frameworks of Aarts et al. [ 21 ] and Katsma et al. [ 31 ]. These studies recognize that EHR implementation is relatively unpredictable due to unforeseen contingencies for which one cannot plan. With their emphasis on emergent change with unpredictable outcomes, Aarts et al. [ 21 ] make a case for acknowledging that unexpected and unplanned contingencies will influence the implementation process. They argue that the changes resulting from these contingencies often manifest themselves unexpectedly and must then be dealt with. Additionally, Takian et al. [ 37 ] state that it is crucial to contextualize an EHR implementation so as to be better prepared for unexpected changes.

C5: Establishing 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 the participation of clinical staff, Ovretveit et al. [ 32 ], Simon et al. [ 36 ] and Weir et al. [ 19 ] build a case for using an interdisciplinary implementation group. By having all the direct stakeholders working together, a better EHR system can be delivered faster and with fewer problems.

C6: Resistance of clinical staff, in particular of physicians, is a major barrier to EHR implementation, but can be reduced by addressing their concerns

Clinical staff’s attitude is a crucial factor in EHR implementation [ 36 ]. Particularly, the physicians constitute an important group in hospitals. As such, their possible resistance to EHR implementation will form a major barrier [ 29 , 33 ] and may lead to workarounds [ 26 ]. Whether physicians accept or reject an EHR implementation depends on their acceptance of their work practices being transformed [ 22 ]. The likelihood of acceptance will be increased if implementers address the concerns of physicians [ 24 , 28 , 32 , 33 ], but also of other members of clinical staff [ 36 ].

C7: Identifying champions among clinical staff reduces resistance

The previous finding already elaborated on clinical staff resistance and suggested reducing this by addressing their concerns. Another way to reduce their resistance is related to the process of implementation and involves identifying physician champions, typically physicians that are well respected due to their knowledge and contacts [ 32 , 33 ]. Simon et al. [ 36 ] emphasize the importance of identifying champions among each stakeholder group. These champions can provide reassurance to their peers.

C8: Assigning a sufficient number of staff and other resources to the EHR implementation process is important in adequately implementing the system

Implementing a large EHR system requires considerable resources, including human ones. Assigning appropriate people, such as super-users [ 36 ] and a sufficient number of them to that process will increase the likelihood of success [ 19 , 32 , 33 , 36 ]. Further, it is important to have sufficient time and financial resources [ 26 , 32 ]. This finding is also relevant in relation to finding A6 (ensuring good care during organizational change).

These 19 general findings have been identified from the individual findings within the 20 analyzed articles. These findings are all related to one of the three main and interacting dimensions of the framework: six to context, five to content, and eight to process. This identification and explanation of the general findings concludes the results section of this systematic literature review and forms the basis for the discussion below.

This review of the existing academic literature sheds light on the current knowledge regarding EHR implementation. The 21 selected articles all originate from North America or Europe, perhaps reflecting a greater governmental attention to EHR implementation in these regions and, of course, our inclusion of only articles written in English. Two articles were rejected for quality reasons [ 43 , 44 ], see Appendix B. All but one of the selected articles have been published since 2000, reflecting the growing interest in implementing EHR systems in hospitals. Eight articles built their research on a theoretical framework, four of which use the same general lens of the sociotechnical approach [ 21 , 22 , 26 , 37 ]. Katsma et al. [ 31 ] and Rivard et al. [ 34 ] focus more on the social and cultural aspects of EHR implementation, the former on the relevance for, and participation of, users, the latter on three different cultural perspectives. Ford et al. [ 27 ] researched adoption strategies for EHR systems and Gastaldi et al. [ 26 ] consider them as a means to renew organizational capabilities. It is notable that the other reviewed articles did not use a theoretical framework to analyze EHR implementation and made no attempt to elaborate on existing theories.

A total of 127 findings were extracted from the articles, and these findings were categorized using Pettigrew’s framework for strategic change [ 13 ] as a conceptual model including the three dimensions of context, content, and process. To ensure a tight focus, the scope of the review was explicitly limited to findings related to the EHR implementation process, thus excluding the reasons for, barriers to, and outcomes of an EHR implementation.

Some of the findings require further interpretation. Contextual finding A1 relates to the demographics of a hospital. One of the assertions is that privately owned hospitals are less likely than public hospitals to invest in an EHR. The former apparently perceive the costs of EHR implementation to outweigh the benefits. This seems remarkable given that there is a general belief that information technology increases efficiency and reduces process costs, so more than compensating for the high initial investments. It is however important to note that the literature on EHR is ambivalent when it comes to efficiency; several authors record a decrease in the efficiency of work practices [ 25 , 33 , 35 , 38 ], whereas others mention an increase [ 29 , 31 ]. Finding A2 is a reminder of the importance of carefully selecting an appropriate vendor, taking into account experience with the EHR market and the maturity of their products rather than, for example, focussing on the cost price of the system. Given the huge investment costs, the price of an EHR system tends to have a major influence on vendor selection, an aspect that is also promoted by the current European tendering regulations that oblige (semi-) public institutions, like many hospitals, to select the lowest bidder, or the bidder that is economically the most preferable [ 45 ]. The finding that EHR system implementation is difficult because good medical care needs to be ensured at all times (A6) also deserves mention. Essentially, many system implementations in hospitals are different from IT implementations in other contexts because human lives are at stake in hospitals. This not only complicates the implementation process because medical work practices have to continue, it also requires a system to be reliable from the moment it is launched.

The findings regarding the content of the EHR system (Category B) highlight the importance of a suitable software product. A well-defined selection process of the software package and its associated vendor (discussed in A2) is seen as critical (B5). Selection should be based on a careful requirements analysis and an analysis of the experience and quality of the vendor. An important requirement is a sufficient degree of flexibility to customize and adapt the software to meet the needs of users and the work practices of the hospital (finding B1). At the same time the software product should challenge the hospital to rethink and improve its processes. A crucial condition for the acceptance by the diverse user groups of hospitals is the robustness of the EHR system in terms of availability, speed, reliability and flexibility (B2). This also requires adequate hardware in terms of access to computers, and mobile equipment to enable availability at all the locations of the hospital. Perceived ease of use of the system (B4) and the protection of patients’ privacy (B4) are other content factors that can make or break EHR implementation in hospitals.

The findings on the implementation process, our Category C, highlight four aspects that are commonly mentioned in change management approaches as important success factors in organizational change. The active involvement and support of management (C1), the participation of clinical staff (C2), a comprehensive implementation strategy (C4), and using an interdisciplinary implementation group (C5) correspond with three of the ten guidelines offered by Kanter et al. [ 46 ]. These three guidelines 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 in several of the analyzed articles. Three Category C findings (C2, C6, and C7) concern dealing with clinical staff given their powerful positions and potential resistance. Physicians are the most influential medical care providers, and their resistance can delay an EHR implementation [ 23 ], lead to at least some of it being dropped [ 21 , 22 , 34 ], or to it not being implemented at all [ 33 ]. Thus, there is ample evidence of the crucial importance of physicians’ acceptance of an EHR for it to be implemented. This means that clinicians and other key personnel should be highly engaged and motivated to contribute to EHR. Prompt feedback on requests, and high quality support during the implementation, and an EHR that clearly supports clinical work are key issues that contribute to a motivated clinical staff.

Analyzing and comparing the findings enables us to categorize them in terms of subject matter (see Table  7 ). By categorizing the findings in terms of subject, and by totaling the number of articles related to the individual findings on that subject, one can deduce how much attention has been given in the literature to the different topics. This analysis highlights that the involvement of physicians in the implementation process, the quality of the system, and a comprehensive implementation strategy are considered the crucial elements in EHR implementation.

Notwithstanding the useful results, this review and analysis has some limitations. Although we carefully developed and executed the search strategy, we cannot be sure that we found all the relevant articles. Since we focused narrowly on keywords, and these had to be part of an article’s title, we could have excluded relevant articles that used different terminology in their titles. Although searching the reference lists of identified articles did result in several additional articles, some relevant articles might still have been missed. Another limitation is the exclusion of publications in languages other than English. Further, the selection and categorization of specific findings, and the subsequent extraction of general findings, is subjective and depends on the interpretations of the authors, and other researchers might have made different choices. A final limitation is inherent to literature reviews in that the authors of the studies included may have had different motives and aims, and used different methods and interpretative means, in drawing their conclusions.

The existing literature fails to provide evidence of there being a comprehensive approach to implementing EHR systems in hospitals that integrates relevant aspects into an ‘EHR change approach’. The literature is diffuse, and articles seldom build on earlier ones to increase the theoretical knowledge on EHR implementation, notable exceptions being Aarts et al. [ 21 ], Aarts and Berg [ 22 ], Cresswell et al. [ 26 ], and Takian et al. [ 37 ]. The earlier discussion on the various results summarizes the existing knowledge and reveals gaps in the knowledge associated with EHR implementation. The number of EHR implementations in hospitals is growing, as well as the body of literature on this subject. This systematic review of the literature has produced 19 general findings on EHR implementation, which were each placed in one of three categories. A number of these general findings are in line with the wider literature on change management, and others relate to the specific nature of EHR implementation in hospitals.

The findings presented in this article can be viewed as an overview of important subjects that should be addressed in implementing an EHR system. It is clear that EHR systems have particular complexities and should be implemented with great care, and with attention given to context, content, and process issues and to interactions between these issues. As such, we have achieved our research goal by creating a systematic review of the literature on EHR implementation. This paper’s academic contribution is in providing an overview of the existing literature with regard to important factors in EHR implementation in hospitals. Academics interested in this specific field can now more easily access knowledge on EHR implementation in hospitals and can use this article as a starting point and build on the existing knowledge. The managerial contribution lies in the general findings that can be applied as guidelines when implementing EHR in hospitals. We have not set out to provide a single blueprint for implementing an EHR system, but rather to provide guidelines and to highlight points that deserve attention. Recognizing and addressing these aspects can increase the likelihood of getting an EHR system successfully implemented.

Appendix A - List of databases

This appendix provides an overview of all databases included in the used search engines. The databases in italic were excluded for the research as these databases focus on fields not relevant for the subject of EHR implementations.

Web of Knowledge

Web of Science

Biological Abstracts

Journal Citation Reports

Academic Search Premier

AMED - The Allied and Complementary Medicine Database

America : History & Life

American Bibliography of Slavic and East European Studies

Arctic & Antarctic Regions

Art Full Text ( H.W. Wilson )

Art Index Retrospective ( H.W. Wilson )

ATLA Religion Database with ATLASerials

Business Source Premier

Communication & Mass Media Complete

eBook Collection ( EBSCOhost )

Funk & Wagnalls New World Encyclopedia

Historical Abstracts

L ’ Annéephilologique

Library, Information Science & Technology Abstracts

MAS Ultra - School Edition

Military & Government Collection

MLA Directory of Periodicals

MLA International Bibliography

New Testament Abstracts

Old Testament Abstracts

Philosopher ’ s Index

Primary Search

PsycARTICLES

PsycCRITIQUES

Psychology and Behavioral Sciences Collection

Regional Business News

Research Starters - Business

RILM Abstracts of Music Literature

The Cochrane Library

Cochrane Database of Systematic Reviews

Cochrane Central Register of Controlled Trials

Cochrane Methodology Register

Database of Abstracts of Reviews of Effects

Health Technology Assessment Database

NHS Economic Evaluation Database

About The Cochrane Collaboration

Appendix B - Quality assessment

The quality of the articles was assessed with the Standard Quality Assessment Criteria for Evaluating Primary Research Papers [ 18 ]. Assessment was done by questioning whether particular criteria had been addressed, resulting in a rating of 2 (completely addressed), 1 (partly addressed), or 0 (not addressed) points. Table  8 provides the overview of the scores of the articles, (per question) for qualitative studies; Table  9 for quantitative studies; and Table  10 for mixed methods studies. Articles were included if they scored 50% or higher of the total amount of points possible. Based on this assessment, two articles were excluded from the search.

Appendix C - All findings

Table  11 displays all findings from the selected articles. The category number is related to the general finding as discussed in the Results section.

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We acknowledge the Master degree program Change Management at the University of Groningen for supporting this study. We also thank the referees for their valuable comments.

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AB and JV established the research design and made significant contributions to the interpretation of the results. They supervised AV throughout the study, and participated in writing the final version of this paper. AV contributed substantially to the selection and analysis of included papers, and wrote a preliminary draft of this article. All authors have read and approved the final manuscript.

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Boonstra, A., Versluis, A. & Vos, J.F.J. Implementing electronic health records in hospitals: a systematic literature review. BMC Health Serv Res 14 , 370 (2014). https://doi.org/10.1186/1472-6963-14-370

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Electronic Health Record (EHR) is one of the most important applications in the healthcare domain which has many benefits for the healthcare community as a whole. The objective of our study is to conduct a comprehensive systematic literature review regarding the EHR adoption over the various healthcare contexts in order to identify the used adoption theories and their most significant factors in EHR adoption. We searched databases including ScienceDirect, PubMed, IEEE Digital Library, Web of Science, Springer, Scopus and Wiley between January 2005 and July 2017. Consequently, 18 identified papers appeared in 17 international journals and conferences. Eligible studies independently were critically appraised, collected within data extraction form and then thematically analyzed by two reviewers and if necessary, the third author. We found out 9 different models and theories including TAM, UTAUT, TOE, DOI, TPB, TIB, stakeholder theory, institutional theory and social network have been used in EHR adoption contexts and the most significant factors in this contexts were perceived usefulness and perceived ease of use. The results demonstrated that the most studies required the EHR adoption have been performed in the developed countries, in which them most of used questionnaires for data gathering. Adoption of EHR systems is multi-dimensional, complicated, and affected by different types of factors in healthcare organizations. Our findings provide valuable insights and shed some light on researchers, decision and policy makers and managers of healthcare domain to make more informed decisions about the adoption and use of EHR systems.

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Farahnaz Sadoughi

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Sadoughi, F., Khodaveisi, T. & Ahmadi, H. The used theories for the adoption of electronic health record: a systematic literature review. Health Technol. 9 , 383–400 (2019). https://doi.org/10.1007/s12553-018-0277-8

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A Literature Review of Electronic Health Records in Chiropractic Practice: Common Challenges and Solutions

The purpose of this study was to review the literature on current challenges and propose solutions for the optimal utilization of the electronic health records (EHRs) in chiropractic practice.

A search was performed in the PubMed, Index of Chiropractic Literature, and Current Index to Nursing and Allied Health Literature databases from November 2005 to February 2015. A combination of the following key words was used: electronic health records , electronic medical records , implementation , documentation , benefits , and challenges . Articles were categorized into common problems and solutions. These were filtered by application to chiropractic or educational institutions.

The search resulted in 45 papers, which included case reports of EHR implementation, governmental insurance reports, commentaries, controlled studies, narrative reviews of past experiences with conversion from paper systems, and the implementation of EHRs in small offices and chiropractic offices. Minimal literature was found that directly related to chiropractic EHRs. Improper utilization, incorrect use of the software, faulty implementation, workflow burdens, financial considerations, and insufficient training were found to negatively affect the quality of the record.

Conclusions

Documentation errors are often innate in the EHR software. Improper utilization, insufficient training, or difficulty in integration of the EHR into the clinical office setting results in poor implementation of the electronic version of the clinical record. Solutions that may decrease documentation errors include EHR training, continued financial incentives, and appropriate implementation process and utilization of available software features.

Introduction

The quality of health care records came into question in the 1960s when Weed 1 published a report on the lack of interprofessional communication about patient care that was affecting the quality of the care rendered. He created the problem-oriented medical record (POMR) and opined that the health care record was “central to patient care and the teaching of healthcare.” 1 The POMR provided organization of the health care record and continuity of care between physicians and interns. 1 This improved patient care, and the system was eventually adopted by medicine and then by other health care providers. Fifteen years later, the chiropractic profession instituted this system. Thereafter, the third-party payors required an increased level of documentation of the medical necessity of care. By the late 1990s, managed care reinforced the necessity of a POMR and the daily SOAP (Subjective, Objective, Assessment, and Plan) notes. Licensing board complaints, regarding the insufficient quality of the records, resulted in the introduction of new board policy guidelines and regulations on documentation and record keeping. 2 , 3 Many managed care organizations also issued policy guidelines. In 2006, the Federation of Chiropractic Licensing Boards passed a resolution that further strengthened the implementation of appropriate documentation. This resolution recommended that “all state boards require a course in the topic of documentation for re-licensure,” and that the Council of Chiropractic Education (CCE) “accredited colleges provide training in documentation in the basic Doctor of Chiropractic curriculum.” 3 Documentation of the clinical encounter with the patient and the decision-making process became a required part of the clinical record. In 2008, the chiropractic “best practices” document informed the clinician of the importance of the clinical process during the encounter. 4 Meanwhile, payors increased the extent and the degree of the record reviews. 5 Despite the professional recommendations and insurance requirements, the American Chiropractic Association stated that the lack of appropriate documentation in clinical records continued to show up in audits and was compromising the practices of a number of practitioners because of third-party payor denials. 6 , 7 , 8

This necessity of an increased level of documentation created a burden on the practicing clinician, which led to evolution of the electronic format. Early efforts to enter the electronic health record (EHR) movement resulted in the implementation of barcoded note-capturing software, rather than a true EHR. The software was expected to increase doctor efficiency and decrease the time for documentation. The software companies imagined their barcoded systems would enable practitioners to see more patients in their workday. The weakness in this initial EHR system is that it only provided an organized directory of patients’ health without sufficient variability or customization to clearly document the specifics of the patient encounter. 5 , 9 This resulted in repetition of language, findings, courses of care, outcomes, duration, and dosages. This type of note-capturing generates similar daily notes because of the electronically generated repetitive information. It failed to substantiate the care rendered. 5

There are currently numerous EHR software programs available for the practicing doctor of chiropractic. However, it is unknown how the practitioner may know which EHR system is most appropriate for clinical documentation or how he or she should implement it for maximum utility. Therefore, the purpose of this paper is to review the literature of the current challenges of chiropractic EHRs and to provide suggestions for future direction.

The literature search was conducted from November 2014 through February 2015. STARLITE (sampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, electronic sources) search strategy with the terms documentation , electronic health record , implementation , benefits , and challenges was used 10 ( Fig 1 ). The study included narrative reviews, commentaries, case studies, case series, surveys, clinical case studies, randomized controlled studies, governmental reports, and insurance company reports. The study also included reports on the progress of implementation of EHRs, quality of documentation, or experience in teaching facilities. The search was limited to the English language, and the databases searched were PubMed, Current Index to Nursing and Allied Health Literature, and Index of Chiropractic Literature. The search was further limited to articles directly applicable to small chiropractic offices and teaching clinics. Reference tracking was used to identify additional citations. Large national network or hospital studies, radiology- or laboratory-related studies, and studies that involved specific conditions were excluded because the implementation problems were not likely to be applicable to individual chiropractic practice or teaching facilities. The final results eliminated duplicates and those citations that were not relevant to the topics of interest.

Search strategy diagram. STARLITE, sampling strategy, type of study, approaches, range of years, limits, inclusion and exclusions, terms used, electronic sources .

A total of 45 full-text articles from all databases were used. There were reports of implementation in small medical offices, 11 satisfaction with EHR systems, 12 , 13 and methods of importing the documentation content. 14 All of these reports indicated consistent problems that affected the quality of the documentation. Commentaries revealed the use and misuse of the documentation information generated by EHR systems. 14 One study looked at the sociological aspect of EHR systems and how it affected the quality of care. 15 This study provided insight into the doctor-computer-patient relationship, with the computer demanding more attention than the patient. The computer intervention resulted in the doctor missing nonverbal patient communication, resulting in a negative effect on quality of care. There were 10 governmental and private insurance reports found and 8 used. These reports reviewed the overall EHR system utilization rate and provided an overview of the trend. Common themes noted throughout the articles reviewed were difficulties in utilization of all the features of the new software, intrusive change in workflow, financial constraints on small office budgets, and imposition in the doctor-patient relationship, which often led to dissatisfaction in practice. There was inconsistent reporting on the effects of EHRs on changes in quality of care but consensus on the other issues.

An analysis of the utilization reports demonstrated an increase in health care utilization of EHRs over the past 14 years. Hing 16 reported that the national health statistics manifested 34.8% utilization by office-based physicians. This showed an increase of 91% over the 2001 statistics. 16 Use increased from 34% to 78% of office-based physicians in 2013. 17 Current usage in chiropractic has been estimated by Smith of the American Chiropractic Association to be only 33% of the profession, lagging behind other office-based physicians. 18 Electronic health record conversion from paper files increased over the past 12 years. Group practices were more likely to use EHRs (74.3%) than solo practices were (20.6%). A higher use rate of EHRs was found in multispecialty practices (52.5%) than in single-specialty (30.3%) or in non-hospital associated practices (20%) or nonacademic practices (14%). 16 , 19 , 20 To increase the utilization of EHRs for documentation, the 2009 American Recovery and Reinvestment Act included funding to promote their adoption by practitioners. As of March 2015, $20 billion in incentives were provided to all provider types. 16 Of this amount, $195 million has gone to chiropractic physicians, indicating that there is a growing percentage of federally qualified, meaningful use EHRs in chiropractic offices. 21

The American Recovery and Reinvestment Act also directed health information technology to promote improved quality and efficiency of care and to reduce medical errors. Hospitals adopted EHRs, with 97% reporting possession of a certified EHR and 76% having adopted it in 2014. 22 Smaller practitioner offices were slower in adoption. 22 , 23 In 2008, the American Medical Association (AMA) reported an even lower figure than the national health statistics, with only 17% of office-based physicians utilizing EHRs in some form, and only 4% of these were fully functional in the office. 24 In 2014, the AMA reported only 2% of office-based physicians qualifying for stage 2 meaningful use. 25 It appears that, in spite of the incentives to foster EHR use, actual implementation was slower in the independent offices, and full-feature capabilities were not implemented.

The AMA, the Institute of Medicine, and many nonprofit and professional organizations promoted increased adoption to improve public health, patient safety, quality, medical liability defense, and research. 26 “Pay for Performance Plans” promoted use of EHRs as part of their measurement for quality-of-care goals. This was reinforced in November 2016 by Medicare with a new rule that promotes a merit-based incentive payment system through the certified EHR technology. 27 The Agency for Healthcare Research and Quality reported that use of EHRs supported a consistently higher standard of care across the country. 28

To the best of the author’s knowledge, this is the first paper to review the literature on the challenges and solutions to EHR implementation in chiropractic practice. The findings indicate that the primary challenges with EHRs were in proper documentation, financial constraints, logistical changes in workflow, intrusion into the doctor-patient relationship, and difficulty in implementing the new process. The literature revealed the potential pitfalls of introduction of new errors into patient records. The pitfalls differed depending on the size of the practice, health care system, or teaching facility.

Challenges: Documentation Errors

This literature review revealed the common occurrence of problems with the use of templates and macros. 12 These generated an unnecessary volume of notes with redundant and irrelevant information. The high volume resulted in inefficiency of review time, similar to illegible handwritten notes. In many instances, template-based notes introduced false information to the record as a result of the user clicking a wrong box, calling up old data, or using old notes as a template with failure to update that portion of the data or note. Doctor transition would exacerbate this problem, when one doctor took over care from another. The new doctor may not have been familiar with the software and might have relied on the previous notes by invoking the “copy forward” notes option without updating the case. This is particularly apparent in teaching clinics. Weis points out that “templates, macros, automated data points, and copy-forward of an entire old note are just a few of the content-importing technology techniques” 14 that create efficiencies of care and opportunities to improve the delivery of care and track the care but are often abused and misused, resulting in misrepresentation of the patient encounter as a result of cloned notes. The Veterans Administration reviewed 243 patient records from 1993 to 2002 and found that 2645 notes contained significant amounts of copied text, indicating a high prevalence in that care organization. This included diagnostic errors that were inadvertently copied and pasted from previous notes. 14 This literature analysis revealed these practices to be a common occurrence in the records. This practice prohibited the integration of the appropriate clinical evidence into the EHR.

Although positive software features were available to improve the documentation, there was reported insufficient utilization of these features. 29 Boonstra’s systematic review provided a good summary of the problems with EHRs. He concluded that this major change in a practice requires a “change manager” to oversee all of the implementation. 30 He also pointed out that various barriers to full utilization of all available software features contributed to these errors as an underlying cause. 23 , 30

The Medicare Comprehensive Error Rate Testing review process found many common errors being carried through from the written record to the EHR entry. Although the notes are more legible than the written record, the carry-through errors include incomplete progress notes with insufficient detail, lack of a date or a signature, and lack of documentation of orders of different procedures or care plans. The Medicare chiropractic reviews revealed insufficient documentation to prove that care was not maintenance care. 31 Thorough documentation is necessary for third-party payors to evaluate the medical necessity of care. It is also necessary for quality of care. Electronic health records are intended to overcome the problems of insufficient clinical detail by providing the basic clinical, financial, legal, and insurance needs of documentation 32 ( Fig 2 ). However, the reviewed literature revealed that there is a high rate of failure of the utilization of all of the features of EHRs. Poor information is available to inform the practitioner of what is required for utilization of all the features of the software program and successful implementation of the EHR. 33

Basic requirements of electronic health record system.

Challenges: Barriers to Implementation

Inappropriate EHR implementation can result in financial problems, logistical problems, and inherent misuse or abuse of the EHR ( Fig 3 ). High costs, lack of certification of some products, and initial disruptive effects on practices all contribute to the difficulty in integration of the EHRs into practice. The disconnect among who pays for the EHR, who profits from it, and who is in charge of the implementation presents significant challenges that have prevented full EHR use in small independent offices. 22 , 34 Smaller independent offices have more difficulty absorbing the large upfront costs, decreased revenue during initial implementation, ongoing maintenance costs, and increased costs of hardware and software. 22 , 34 This is in spite of the potential long-term savings.

Challenges in electronic health record (EHR) implementation.

A major implementation barrier was the lack of training of staff and doctors. 35 This resulted in a decreased quality of clinical documentation and subsequent decrease in practice satisfaction. 12 , 13 Other barriers to full software feature implementation of EHRs have been reported to include a lack of incentive because of no vested interest in the EHR system by many users, psychosocial factors, financial factors, insufficient software training and utilization, lack of involvement of all staff in the implementation process, interoperability of different software systems, and a misunderstanding of the basic needs of documentation. 23 , 30 , 34 , 36 , 37

Challenges: Doctor Satisfaction

Doctor satisfaction with use of the EHR is a factor in the degree of implementation and utilization. A RAND (Research and Development corporation) study performed by Friedberg for the AMA in 2013 revealed that the EHR and the resultant implementation burdens they put on practitioners are a major reason for doctor’s lack of satisfaction with practice. 12 Sixty-five percent opined that the EHR failed to improve their job satisfaction. The EHR’s effect on job satisfaction exceeded the effect of health care delivery system changes on doctors’ job satisfaction. Despite this, 61% still felt that the EHR improved the quality of care, but many felt that it interfered with face-to-face time with the patient. This was often due to the doctor having to face the screen to enter data instead of facing the patient, causing him or her to miss body language, emotional responses, or opportunities to ask clarifying questions. Doctors were forced to divide their attention between the computer and the patient. If they chose to provide all their attention to the patient, they were burdened with lengthening their work hours to enter the data at lunchtime or after hours. The doctor is inhibited from creating a trusting, confident relationship with the patient. Surprisingly, in spite of the problems with EHRs, less than 20% of practitioners desired a return to manual records. 12

Benefits of EHR Documentation

Electronic health records have inherent potential benefits that allow for improved quality of the clinical documentation in a more efficient manner. Some of the chiropractic EHR programs link up to a common database of prescription drugs. This allows doctors of chiropractic to obtain important information on the medications a patient takes, which would diminish the reliance on the accuracy of a patient’s ability to recite medication lists. Other programs have specific features to increase efficiency, quality, continuity of care, and patient safety. These benefits should provide an incentive for further EHR utilization by chiropractic physicians. Additional essential contemporary issues that any EHR documentation should satisfy ( Fig 4 ) 38 include protection of the legal liability of the practitioner, enhanced reimbursement, and public health issues.

Essential issues that an electronic health record must satisfy.

Samaan 38 reported that the implementation of EHRs resulted in a decreased frequency of incomplete charts 3 days postvisit and an increase in evaluation/management level coding, which resulted in increased income. There was also an eventual decrease in number of support staff, after the prolong implementation period. 38 This would indicate the potential of EHRs to improve efficiency and improve the budget of the chiropractic office. Liang 39 noted a perspective about the potential of EHRs to introduce new evidence from the patient population and to diffuse literature-based evidence into practice more quickly via integration of best practices into the clinical support software. 39 This creates potential to enhance the ability of the chiropractic practitioner to improve the clinical documentation, decision making, and quality of care. Additional long-term savings through financial efficiencies and decreased staff are also reported, 38 which support the financial benefit to the small chiropractic office.

As Dr. Weed stated 45 years ago, the clinical record is still central to care. 1 This remains true, regardless of the format. However, the realization of the potential advantages of EHRs has lagged behind the implementation in spite the increased adoption rate. Regardless, the literature reports continue to expound the potential. 40 Electronic health records literature specific to chiropractic practice is sparse. This review revealed only 4 peer-reviewed manuscripts and other trade journal, association, and governmental reports that address chiropractic documentation.

Recommendations for the Profession

Basic needs of documentation.

Chiropractic EHR systems need to have features that allow customization of each encounter, to allow the appropriate documentation that attends to the basic documentation needs. Gutheil outlined 3 basic principles for documentation ( Fig 2 ): the risk-benefit analysis, the use of clinical judgment, and patients’ capacity to participate in their own care. 41 He refers to the necessity to document not only the risks, but also the benefits of care. This is especially important to comply with fully informed consent. It also protects the clinician’s liability and segues to the second principle of documenting the clinical judgment. An important factor related to clinical judgment is that it must be congruent with the clinical needs documented in the subjective presentation, objective findings, and overall patient assessment. The third principle states that the patient should be the primary master. Therefore, the records, whether written or electronic, need to relate the participation of the patient in his or her own care. This can be done through direct quotes in the subjective section, outcome measures, or recording the patient’s responses to the care. Documentation of these principles is difficult with preprogramed macros and templates and need customization.

To integrate the clinical data in an appropriate manner, it is recommended that the provider purchase and implement an EHR that fulfills the basic needs ( Fig 2 ). Copied or cloned information must be reviewed and edited by the provider with each note generation. The note must be specific and pertinent to that clinical encounter. Copying entire sections of a document should be prohibited to avoid note redundancy. Students and doctors need to be trained to avoid overdocumentation by inserting false or irrelevant information. Training should also include proper use of macros, templates, or repetitive auto-population of fields in the software system. Histories, and both subjective and objective findings, need to be specifically constructed on each visit. Electronic health records will not innately correct carry-forward input problems. Repetitive pasting or carrying forward of the diagnosis in the Assessment section of the daily note fails to provide any ongoing clinical decision making. This is vital to support the level of the coding or the substantiation of the care. In consideration of federal compliance and legal protection, even with a sophisticated EHR system, there must be capability for the individual doctor to sign the notes. In doing so, the signer acknowledges responsibility for the content.

Funding of EHRs in Chiropractic

Small offices, which predominate in chiropractic, have financial difficulties in making the change to EHRs. The government incentive has expired, and other incentives are needed that encourage the change. Ryan 42 reported that financial incentives for conversion to EHRs promote implementation with associated quality in care. One such experiment was successfully instituted by North Shore Hospital, NY. They found that most offices that lacked EHRs were small offices. Ryan reported an offer of up to $40 000 per office for the conversion to, and implementation of, EHRs. The study found that financial incentives and technical support resulted in improved quality of care. 43 This study provides an indication of the need for ongoing financial incentives as governmental incentives expire. Because the majority of chiropractic practices are small offices, a similar incentive by payors would help in the sharing of the expense for the demands of the payors.

Purchasing EHRs

The ability to integrate the appropriate clinical data into the EHR is dependent on the quality of the software purchased. In consideration of the level of technical, compliance, and documentation knowledge and sophistication of the average doctor of chiropractic, providers need preliminary EHR training to guide them in their EHR evaluation and purchase. McGregor 37 did a fine job of outlining the stages of evaluation. A number of pointed questions are outlined for advice ( Fig 5 ). Diamond et al 44 also provide a nice scorecard to compare vendors. They set up a method of comparing vendors and looking at support, hardware, software, workflows, and reporting with specific criteria outlined. 44 Maust 35 discusses the necessary training and outlines specific questions to ask vendors. Without proper purchase and training, documentation would remain insufficient, regardless of the investment.

Questions to ask when purchasing an electronic health record (EHR) system. (Data from McGregor. 38 )

EHR Implementation

After an appropriate EHR purchase is made, the ability to integrate the clinical data is still contingent on an implementation plan for all doctors, interns, staff, and allied health assistants. The success of full implementation and utilization of all features depends on the training. 45 This includes the training in the sociological aspect of utilizing the EHR during the patient contact. Some suggestions are intuitive but need to be emphasized ( Fig 6 ). 15 , 36 , 46 , 47

Recommendations for optimal electronic health record (EHR) implementation and documentation. (Data from Maust, 35 Fleurant, 45 Bostrom, 36 Torda, 46 Fredericks, 15 and Lyons. 47 )

Wuerth 48 makes the following additional suggestions: Be patient; competency in EHRs can take up to a year. Until that time, one can expect a decrease in productivity. He also emphasizes the importance of not allowing the EHR to direct patient contact, but that it is important to allow patients to participate in the EHR. Facing the patient instead of the computer for most of the encounter is integral to the contact.

In spite of the difficulties, the training of new doctors will need to include how to integrate quality data and any literature references into the documented electronic record. Training in the appropriate EHR begins with the new doctors entering the occupation. Interns in teaching institutions may only obtain an introduction to EHRs. They will often have insufficient time in their clinic rotations to become competent and proficient. 48 It might be difficult to institute EHRs in a teaching clinic, unless the attending clinicians are the primary providers of care vs the interns. It is likely that workflows would never get established because of the ongoing EHR learning, adaptation periods, and transitional nature of interns. The constant transition period would cause longer patient wait times and further prolong the intern-patient contact time, decrease patient flow, and diminish income. Because of the growing need for the chiropractor to provide clinical evidence in the documentation, it is still suggested that interns be provided additional training and simulated entries for virtual patients before entering the clinical environment.

Most EHR documentation errors are innate in the EHR software. As an incidental note, the high prevalence of inherent errors from these sources, regardless of the specialty, appears to contradict a perception of documentation fraud by the individual practitioner. Chiropractic record improvement will require diligence to the educational process, purchase of the appropriate EHR software, attention to the implementation process, training of staff and chiropractors, appropriate utilization, and attentiveness to the data entry by the treating doctor. It will also require the practitioner to maximize the existing features of the software and customize it to the practice. Funding from sources outside the chiropractic profession might be necessary to reach all the goals of the quality chiropractic EHR. Until these issues are addressed, the clinical data may continue to be deficient in the EHR. This would result in an ongoing inability to demonstrate the necessity of care.

Finally, documentation serves many stakeholders. Readers other than the treating doctor will include the consulting doctor, other health care practitioners involved in the care, the payor, the insurer, the reviewer, and, if it goes to court for any reason, the attorney. The necessary contents of the record are outlined in Medicare meaningful use criteria and by the National Committee for Quality Assurance. 49 Most of these government and quality assurance guidelines target the primary care practitioner. Although some of it does not immediately apply to chiropractic practitioners, they are now being held responsible to a similar level of documentation by the payors. Overall, if doctors of chiropractic can follow the recommendations in this paper, then they can provide sufficient clinical documentation in the electronic record for all potential readers of the record. Additional resources on EHR implementation are available through the American Academy of Family Physicians and the National Institutes of Health. 50 , 51 , 52

Limitations

Because this was a narrative review aimed at generating possible directions for the chiropractic profession, it was limited in scope. The search strategy used may have missed relevant papers. In addition, other important search engines were not used, and therefore, relevant papers to this topic may have been omitted. The search and review was performed by only one person, so some bias may have been introduced with interpretation.

This review revealed that the current quality of the documentation in EHRs remains a challenge, with insufficient documentation to substantiate the quality and necessity of care. Common errors in using the EHRs were found in both chiropractic and other health care practitioners. These errors were more often a result of problems with software misuse or abuse, budgetary constraints, insufficient training, or carry-forward errors from manual methods. Electronic health records training, continued financial incentives, appropriate implementation processes, and utilization of available software features may decrease documentation errors.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Acknowledgments

The author thanks Claire Noll, MS, CGS, MLIS, of the Texas Chiropractic College Library system for her helpful assistance. The author acknowledges Dr. John Ward and Dr. Cheryl Hawk for their input with this manuscript.