All studies initially reviewed were screened for data on barriers to adoption and implementation. For this analysis, qualitative studies that were primarily focused on barriers and studies that collected quantitative data on barriers were included. Studies in which barriers were briefly discussed, but were not a primary focus, were excluded. A primary focus on barriers was identified through reviewer consensus.
We identified 20 publications that focused on the barriers to implementing HIT. Of these, 8 reported the actual or potential barriers encountered with specific HIT implementations,1, 2, 3-11 usually as part of an article discussing the implementation. Two articles were short opinion pieces about potential barriers from the physician perspective.12, 13 Two studies assessed the physician time for order entry using CPOE compared to paper methods;5,14 both demonstrated that CPOE took more physician time, although the study by Overhage and colleagues found this additional time to be modest. A third study assessed the effect on primary care physicians' time before and after implementation of an EHR system and reported that the time for a patient visit actually fell by half a minute with EHR use.15 Last, one study compared physician user satisfaction with two HIT systems: the VA CPRS system and the Mt. Sinai hospital physician order entry system. This study demonstrated CPRS users to be much more satisfied than Mt. Sinai hospital users on many dimensions and also demonstrated that satisfaction was correlated most SUPly with the ability of the HIT system to perform tasks in a "straightforward" manner.4 Finally, one article was a systematic review of physician use of electronic retrieval systems such as Medline.16
The other five articles focused more broadly on barriers to HIT implementation. One systematic review17 summarized barriers mentioned in the medical and pediatric literature that are significant for pediatric practices. These barriers were divided into four categories. Situational barriers included time and financial pressures, unproven return on investment, insufficient access to the internet or to computer technology in the office setting, the prohibitive cost of information technology for small practices, and software not being supportive of pediatric practice needs. Cognitive and or physical barriers include physical disabilities and insufficient computer skills. Liability barriers included confidentiality concerns. Finally, knowledge and attitudinal barriers included insufficient research about information technology in pediatrics, insufficient knowledge about benefits afforded by information technology, apprehension about change, and philosophical opposition to information technology.
Two studies used surveys to identify barriers in the use of electronic medical records18 and barriers to implementing CPOE systems in U.S. hospitals.19 In the first of these studies, the authors conducted 90 interviews with electronic medical record managers and physician champions in 30 physicians' organizations between 2000 and 2002. Key barriers to electronic medical record use were high initial financial costs, slow and uncertain financial payoffs, and high initial costs in terms of physician time. Additional barriers included difficulties with technology, complementary changes in support, electronic data exchange, financial incentives, and physician attitudes. The authors note that these barriers were most acute for physicians in solo/small group practice, which account for a large proportion of U.S. physicians. The second article19 reported the results of 52 interviews at 26 hospitals in various stages of implementation of CPOE from not considering implementation to fully implemented. Most respondents were Chief Information Officers; the remainder consisted of Chief Financial Officers, Chief Medical Officers, and other management officials. Three main barriers to CPOE adoption were identified. The first was physician and organizational resistance due to the perceived negative impact on the physician's workflow. The authors noted that resistance from physicians could escalate to the point of a "physician rebellion," which could derail the entire implementation process. The second barrier identified was the high cost, with estimates from prior studies for the cost of CPOE ranging from $3 million to $10 million, depending on the hospital's size and the level of existing information technology infrastructure. The third major barrier identified was product/vendor immaturity. Survey respondents reported that many current vendor products did not fit the needs of their hospital, and extensive software modifications were required to accommodate established workflow in the hospital.
We also identified two recent prominent editorials about barriers to HIT implementation that summarized the issues succinctly.20,21 The first of these20 identified several challenges for adoption of electronic health records. These included cost, technical issues, system interoperability, concerns about privacy and confidentiality, and a lack of a well trained clinical informatics work force to lead the process. This author identified financing as the biggest impediment, which he attributed to a misalignment of costs and benefits. He noted that while some studies have suggested a substantially positive return on HIT investment for the health care system as a whole, those who are expected to pay for the systems (physicians and other practice organizations) see only about 11% of that return on investment. The rest of the savings go to those who typically do not pay directly for the electronic health record. Another major challenge he identified was system and data interoperability, noting that most health care data (whether on paper or electronic) are trapped in "silos." A third concern was privacy and confidentiality: the author stated that physicians, other health care professionals, and healthcare organizations must be vigilant in protecting patient privacy. The last major barrier identified was the need for a workforce capable of leading the implementation of information technology.
The second editorial21 stated that, despite predictions of a "bright and near future" for the use of HIT, this future never seems to be realized. The authors attributed the lack of progress in HIT implementation to a lack of attention to the social component, citing the need to view the clinical workplace as a complex system in which technologies, people, and organizational routines dynamically interact, which leads to the following observations:
"(1) Organizations are simultaneously social (e.g. consisting of people, values, norms and culture) and technical (i.e., without tools, equipment, procedures, technology and facilities the people could not work and the organization would not exist). (2) These social and technical elements are deeply inter-dependent and inter-related hence the term socio-technical systems. Every change in one element affects the other. (3) Accordingly, good design and implementation is not a technical problem but rather one of jointly optimizing the combined socio-technical system."
The authors also note, "...an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high quality care, the technological interventions will not be productive. This implies that any IT acquisitions or implementation trajectory should, first and foremost, be an organization change trajectory."
In summary, studies have identified a large number of barriers to the implementation of HIT. These barriers can be classified as situational barriers (including time and financial concerns), cognitive and or physical barriers (include physical disabilities and insufficient computer skills), liability barriers (including confidentiality concerns), and knowledge and attitudinal barriers. Cutting across all these categories, however, may be the need for clinical medicine as it is now practiced in the majority of settings to undergo a major structural and ideological reorganization, so it can be integrated with and enjoy the benefits of HIT.
- Kian LA, Stewart MW, Bagby C, et al. Justifying the cost of a computer-based patient record. Healthc Financ Manage 1995;49(7):58-60, 62, 64-7.
- Cameron S, Regalado M, Quitoles M, et al. Harnessing technology: the creation of an electronic care management record in a social health maintenance organization. Manag Care Q 1999;7(1):11-5.
- Overhage JM, Suico J, McDonald CJ. Electronic laboratory reporting: barriers, solutions and findings. J Public Health Manag Pract 2001;7(6): 60-6.
- Murff HJ, Kannry J. Physician satisfaction with two order entry systems. J Am Med Inform Assoc 2001;8(5):499-509.
- Overhage JM, Perkins S, Tierney WM, et al. Controlled trial of direct physician order entry: effects on physicians' time utilization in ambulatory primary care internal medicine practices. J Am Med Inform Assoc 2001; 8(4):361-71.
- Wong DH, Gallegos Y, Weinger MB, et al. Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system.Crit Care Med 2003;31 (10):2488-94.
- Abookire SA, Teich JM, Sandige H, et al. Improving allergy alerting in a computerized physician order entry system. Proc AMIA Symp 2000;2-6.
- Ammenwerth E, Mansmann U, Iller C, et al. Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study. J Am Med Inform Assoc 2003;10 (1):69-84.
- Gamm LD, Barsukiewicz CK, Dansky KH, et al. Investigating changes in end-user satisfaction with installation of an electronic medical record in ambulatory care settings. J Healthc Inf Manag 1998;12 (4):53-65.
- Burkle T, Kuch R, Prokosch HU, et al. Stepwise evaluation of information systems in an university hospital. Methods Inf Med 1999;38(1):9-15.
- Elbourne D, Richardson M, Chalmers I, et al. The Newbury Maternity Care Study: a randomized controlled trial to assess a policy of women holding their own obstetric records. Br J Obstet Gynaecol 1987;94(7):612-9.
- Lazarus SS. Physicians' use of electronic medical records--identifying and crossing the barriers. Med Group Manage J 1999;46(3):12-4.
- Berkowitz LL. Breaking down the barriers. Improving physician buy-in of CPR systems. Healthc Inform 1997;14(10):73-6.
- Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proc Annu Symp Comput Appl Med Care 1994;996.
- Pizziferri L, Kittler AF, Volk LA, et al. Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study. J Biomed Inform 2005;38(3):176-88.
- Hersh WR, Hickam DH. How well do physicians use electronic information retrieval systems? A framework for investigation and systematic review. JAMA 1998;280(15):1347-52.
- Johnson KB. Barriers that impede the adoption of pediatric information technology. Arch Pediatr Adolesc Med 2001;155(12):1374-9.
- Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Aff (Millwood) 2004;23(2):116-26.
- Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff (Millwood) 2004;23(4):184-90.
- Hersh W. Health care information technology: progress and barriers. JAMA 2004;292(18):2273-4.
- Wears RL, Berg M. Computer technology and clinical work: still waiting for Godot. JAMA 2005;293(10):1261-3.