Episode IV: Evolution of Medical Records – Barriers to EMR Adoption
For this, the fourth instalment we look at key research regarding the barriers for Electronic Medical Record (EMR) adoption. In a recent (2010) review of EMR barriers based on research from 1998 to 2009, Boonstra & Broekhuis (1) identified eight categories, four are quantitative and four qualitative but all of which are inter-related.
Finance is cited as the greatest quantitative barrier. The high costs of acquisition (selection, license, hardware & infrastructure), coupled with high costs of training, administration, maintenance, support, upgrades and after-sales service leads to uncertain return on investment, where benefits are promises and costs are upfront. This uncertainty in turn does not aid the capital funding process.
The
technical
barrier relates to the need to upskill the user base. It was cited that most of the current generation of doctors, at least in Ireland, received their qualifications before IT systems were introduced – although it should be conceded that this situation is changing quickly. Users need to be able to type, and going electronic introduces a new error – “typos”. There can be a large learning phase, so the need for a lot of technical training and support should be addressed. This can be compounded by EMR complexity, a complexity that often decreases usability and leads to time barriers. A common complaint is that the EMR does not fit the users needs – it is not easy to customise. Paper is often seen as more reliable than an electronic solution and is not subject to power failure, viruses, downtime etc. (Ikea agrees www.youtube.com/watch?v=MOXQo7nURs0 – Experience the power of a BookBook™). Other elements include the need to integrate with existing and future external systems, and the need for reliable infrastructure such as WiFi, internet, backups, servers etc.
Time is another barrier. A significant amount of time is required upfront to select, acquire, implement and train users, as well as handling the migration of legacy data and paper, usually in the form of scanning. This process can take many months, but more often, many years. Many clinicians prefer to use paper rather than a computer when they interact with patients, as it is quicker. Electronic data entry can be slower partially due to IT complexity and lower technical skills, this means more time spent per patient, thus affecting productivity.
The
legal barrier relates to data-protection concerns, audit trails and security risks. The security profile of a paper record is manifestly different to that of an electronic record, and so there are more legal, governance and insurance considerations with the associated policies and procedures.
The
psychological barrier is one that is not to be underestimated – particularly relative to users. Essentially these are perceived or are personal barriers to adoption – fear, scepticism, negative perceptions or even previous bad experiences. There is also less control over patient information, diagnosis, treatment and follow-up data can be shared and is readily accessible by others.
The Social or
Relationship barrier has a number of facets.
- EMR vendors are seen as IT focused and non-clinical.
- National or hospital group agendas are not aligned with EMR adoption.
- Using technology can affect patient engagement, having to turn away to a computer – though this is more relevant if the EMR is not easy to use. There is more time spent in finding specific functions in an EMR than eye-contact with the patient.
For an EMR to work all parties need to use it so there is a network effect – having some not use it dampens the benefits for others that do.
Organisational factors have some bearing on adoption –larger organisations are more likely to adopt and support an EMR, as costs are commonly an inhibiting factor for smaller organisations. Whether doctors are employed directly by the hospital or are consultants to one or more hospitals has a major impact – particularly related to the contracts for these professionals and their need to learn multiple EMR systems.
The final barrier is the largest of the qualitative group. The
change process affects the implementation and use of an EMR. There is much documented evidence of failed or partially used EMRs never reaching their full potential. Change is required in working practices that users have developed over years in the analog (paper) domain. Technology alone is not sufficient to achieve a well functioning EMR. What’s in it for the clinician – can this be perceived and delivered? Participation is required throughout the organisation and its staff including doctors, nursing, IT and admin staff.
Without doubt, the largest detractors to adoption and successful implementation are those barriers related to finance and to the change process. Most other barriers contribute or are heavily related to these. In the next episode we look at the vicious circles associated with these.
Billy Diggin - Chief Technical Officer, Sláinte Healthcare
Billy joined Sláinte Healthcare in 2009 as Chief Operating Officer, where he has responsibility for day-to-day technical operations, new product development, and commercial assessment of new products and markets. Billy now holds the position of CTO, bringing over 20 years of experience in product and business development in electronics manufacturing and software automation. Billy was VP Engineering and VP Business Development for Xsil, Director of Software, Pentus Technologies. He has a Bachelor’s and Masters Degrees in Engineering from the University of Limerick, and a first class honours MBA from Smurfit Business School, UCD.
(1) www.ncbi.nlm.nih.gov/pmc/articles/PMC2924334