Lorenzi NM et al. 2009 "How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings."

Lorenzi NM, Kouroubali A, Detmer DE, et al. How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings. BMC Med Inf Decis Making 2009;9:15.
"Background: Adoption of [electronic health records] EHRs by U.S. ambulatory practices has been slow despite the perceived benefits of their use. Most evaluations of EHR implementations in the literature apply to large practice settings. While there are similarities relating to EHR implementation in large and small practice settings, the authors argue that scale is an important differentiator. Focusing on small ambulatory practices, this paper outlines the benefits and barriers to EHR use in this setting, and provides a "field guide" for these practices to facilitate successful EHR implementation. Discussion: The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, pre-implementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process. Summary: The EHR implementation experience depends on a variety of factors including the technology, training, leadership, the change management process, and the individual character of each ambulatory practice environment. Sound processes must support both technical and personnel-related organizational components. Additional research is needed to further refine recommendations for the small physician practice and the nuances of specific medical specialties."

To discuss the benefits and barriers to EHR use in small ambulatory practices.

Other Information
The study analyzed small ambulatory physician practices, with five physicians or less. The article "offer[s] a synopsis of what is known about benefits and barriers with special attention to those issues most relevant to smaller practices...[It] is not intended to be a comprehensive review [but] to illustrate the key issues."
Type of Health IT
Electronic health records (EHR)
Type of Health IT Functions
The article discusses various definitions of EHR including "the U.S. Department of Health and Human Services (DHHS) defin[ition of] EHR '...a digital collection of a patient's medical history, including diagnosed conditions, prescribed medications, vital signs, immunizations, lab results, and personal stats like age and weight.'"
Workflow-Related Findings
"An electronic health record has the potential to strengthen the quality of care and the relationship between clinicians and patients through ready access to accurate and up-to-date patient information from office or remote locations."
"An EHR saves staff time otherwise used searching for charts, entering charges manually, etc. Depending on the size of the practice, this 'found time' can be devoted to value-added activities or eliminated, thereby reducing overtime charges. Through the use of EHRs, productivity increases because of improved office efficiency."
"Providers in most practices particularly liked accessing records from home, which enabled some of them to go home earlier. The providers also characterized as an improvement the ability to access records immediately while on call."
"[T]he transition from computer-based administrative information systems to fully-implemented EHRs is a major undertaking that creates dislocation among the clinical staff and is more complicated, more difficult, and more expensive than most practices expected."
"Physicians are now more willing to adopt new technologies when the applications are user-friendly and fit within their daily workflows. Since healthcare providers are willing to use technologies that meet their needs, then the processes of selecting and buying, planning for implementation, and carrying out system implementation must be considered, especially for small practice settings, since to date, most vendor systems have largely been designed for larger practice environments."
"A commonly encountered form of resistance to new system implementation is the complaint that the new system compares unfavorably to the old system. While presenting factual data does not counteract emotional reactions, it is important to address unfounded allegations or rumors about the new system."
"Studies document that an EHR that does not integrate smoothly into clinicians' workflows and that does not allow for variations in style can adversely affect productivity and financial return on investment."
"In medium size practices of more than two doctors, the existence of teamwork is very important in incorporating the EHR in daily practice. Physicians should be working closely together as a team in order to agree on electronic information sharing through a common EHR. In practices where doctors did not communicate well, had other priorities, or did not want to share electronic data, resistance towards EHR implementation was very common. On the other hand, in practices where sharing of information, communication, and collaboration in patient care were well established, the use of EHR as an instrument for continuity of care was easily understood. As the practice of medicine is inherently autonomous, teamwork is not automatically established but gradually developed."
Study Design