Monday, February 1, 2010

The Top 10 Barriers to EHR Implementation

Last week I taught Module II of Leadership Strategies for Information Technology in Healthcare at the Harvard School of Public Health.

My students included administrators, clinicians, CIOs, CMOs, and policymakers.

On the first day, I gave them a homework assignment - read my overview of the BIDMC/BIDPO EHR implementation project and then develop a list of barriers to EHR implementation in their organizations.

Here's the crowd sourcing results of the top 10 barriers to successfully deploying an EHR:

10. Usability - products are hard to use and not well engineered for clinician workflow.

9. Politics/naysayers - every organization has a powerful clinician or administrator who is convinced that EHRs will cause harm, disruption, and budget disasters.

8. Fear of lost productivity - clinicians are concerned they will lose 25% of their productivity for 3 months after implementation. Administrators are worried that the clinicians are right.

7. Computer Illiteracy/training - many clinicians are not comfortable with technology. They are often reluctant to attend training sessions.

6. Interoperability - applications do not seamlessly exchange data for coordination of care, performance reporting, and public health.

5. Privacy - there is significant local variation in privacy policy and consent management strategies/

4. Infrastructure/IT reliability - many IT departments cannot provide reliable computing and storage support, leading to EHR downtime.

3. Vendor product selection/suitability - it's hard to know what product to choose, particularly for specialists who have unique workflow needs

2. Cost - the stimulus money does not flow until meaningful use is achieved. Who will pay in the meantime?

1. People - its's hard to get sponsorship from senior leaders, find clinician champions, and hire the trained workers to get the EHR rollout done. (this was the #1 concern by far)

After we reviewed the real top 10 list, I read a more colorful top 10 list in the Letterman tradition, from a very creative student

10. You need to attend a Harvard Certificate Program to have a clue

9. Meaningful use is only meaningful to academic scholars

8. Docs keep asking - where's my money?

7. The government thinks 2011 is a decade away

6. The government says "do it now, but I will tell you what I want next month"

5. My kids say "hey Dad, I just discovered 10% (i.e. the inpatient CPOE usage requirement) is a passing grade"

4. You read about your security breaches in the New York Times.

3. Patients get to go home early because clinicians are busy implementing software.

2. When you ask vendors how they justify the claim that their products are 2011 certified (and the certification process has not yet been announced), they show you a Ouija Board.

1. You need Ted Williams' batting statistics to convince your Board that EHRs are worthwhile.

There you have it - the actual top 10 from the crowd and the wisdom from someone who's keeping their sanity during this time of great change with a touch of humor.


Ahier said...

Your creative student gets an A+ for this top ten list - I'm still laughing :-D

Great work...

e-Patient Dave said...


The real one's great, too. Valuable input. Thanks. But not priceless.

Pauline Sweetman said...

Difficult to say which bit is best! Loved the ouija board comment.
It's a great (serious) top 10 list too. Good piece of work.

Medical Quack said...

Perception as what lies in the eyes of the potential beholders; we found humor but they are marching to their own tunes:)

Great post:)

@swisshealth20 said...

Dear John,

Great list! Why not skip this generation of actual IT-systems, stop discussing usability and switch directly to ubiquous computing or context awareness. a HAL 9000 for doctors, Healthcare Odessey 2020!

Dan Draper said...

John, I’m very impressed and relieved your “students” brought up infrastructure and IT availability. I find IT infrastructure to be a bigger barrier in ambulatory offices compared to large hospitals. Hospitals typically have an IT infrastructure foundation, but lack of capacity is the problem. Ambulatory is typically starting at square one when building their IT infrastructure, which then creeps into the cost barrier.

Mark S. said...

While I enjoyed the second list and think the first is accurate, what would be more interesting to me is seeing your (and others) responses to these issues. I primarily deal with 1-6 doctor abulatory practices and can tell you, these barriers are a very real obstacles. However, practices that are looking to finally get an EHR primarily for the stimulus package money are severely underestimating their impact on a successful implementation. Not only that, many practice are going to try and rush through the selection and purchase process in an attempt to get this perceived "free money" as soon as they can, without a realistic understanding of how using an EMR will affect their personal workflow. The next 2 years are going to be filled with many failed implementations and buyer's remorse as a result. Practices that get burned on bad practice management system can generally switch without much issue to something that works. A bad EHR implementation can be crippling to a practice both financially and to the quality of medical care they can provide. A potential $44,000 in government funds over 5 years isn't going to able to change that, not to mention that if a practice chooses poorly or implements poorly, they wont get that money anyway...

The benefits of ARRA just seems to be focused on the big players (hospitals, large EHR vendors) to the detriment of small clinics and vendors. I hope to be proven wrong.

AJ Chen said...

It's so funny, and yet so real. I like the list of unspoken true. I'm wondering whether your students will be equally creative in coming up with a list of drivers for the health IT transformation.

Molly Oehmichen said...

Excellent post. As an ambulatory EMR consultant, I battle all 10 of these issues daily.

My only comment is that I think #10 is really the biggest problem- if there was an EHR built around usability instead of all of the old technology currently in use, the other 9 barriers would be hardly significant.

The future of Health IT is encased in small touchpad devices, with software made FOR clinicians, and not in spite of them.

Jennifer Dennard said...

Hmmm ... I doubt this is the first time a Ouija board has been mentioned in the same breath as healthcare. Great article, thanks.

Unknown said...

I'm a former software product manager and some of the issues on this top 10 list (whichever) is deeply rooted in how the software was developed.

Long before these products had come to market, they were designed 2-5 years before, when traditional product management was an afterthought. Whence down the road, the design cannot be changed and the users have to conform to the software.

I believe that EHRs are inherently a documentation product for the financial side first, hence it's difficulty to suit clinicians. If clinicians are included, it is an afterthought and much effort is expended to make the clinical conform to the paradigm of the EHR software.

ehr software said...

is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patent's medical records across facilities.


Mark MD said...

Thank you for this insightful post. A+ for creativity.. It is so true and I am still laughing.

I think one of the greatest hurdles is overcoming misconceptions in the minds of regulators, doctors and patients alike. I just returned from a trip to Germany and colleagues there are amused about America's 3rd World-like medical records situation. Then again we also have a 3rd World like banking system to process payments.

They say laughing is the best medicine, so thanks again for the medication!