Zandieh SO et al. 2008 "Challenges to EHR implementation in electronic-versus paper-based office practices."

Zandieh SO, Yoon-Flannery K, Kuperman GJ, et al. Challenges to EHR implementation in electronic-versus paper-based office practices. J Gen Intern Med 2008;23(6):755-761.
"BACKGROUND: Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems. OBJECTIVE: To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based). DESIGN: Qualitative study. PARTICIPANTS: Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006. APPROACH: Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0. RESULTS: We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. CONCLUSIONS: Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges."
To "compare and contrast perceived benefits and challenges to [EHR] implementation between paper- and electronic-based practice leaders."
Tools Used
Type Clinic
Primary care
Type Specific
Internal medicine, OB/GYN, pediatrics, geriatrics, and family practice
Small, medium and large
Other Information
The study was conducted in an academic ambulatory care network of a large teaching hospital in New York City. The number of patient visits per clinic ranged from 9,600 - 76,000.
Type of Health IT
Electronic health records (EHR)
Type of Health IT Functions
The EHR allows clinicians to "[c]ollect health information and data, review results, order tests and laboratory analyses, provide decision support, facilitate electronic communication and connectivity through remote access, and create registries."
Context or other IT in place
"Some practices had electronic systems that included virtually all patient data (e.g., those with legacy [electronic health record] EHR systems), whereas others were limited to certain types of electronic data, such as ordering or reviewing medications an
Workflow-Related Findings
"A respondent felt that resources were not efficiently allocated: 'Physicians were told to all go across the hall to the networked, shared printer to pick up printed prescriptions during each visit... [so] we requested additional printers be stationed in exam rooms.'"
"Remote access allows practitioners to work more efficiently from home [especially] when taking night calls." "One [physician] stated an EHR would 'enable physicians to provide more knowledgeable advice during off-site/off-regular hours.'"
"[The authors expected] improved communication between inpatient and ambulatory practices; information retrieval between these two [sites] is currently difficult and time-consuming."
"Another respondent stated, 'there will be great resistance by practitioners against the new EHR implementation, particularly since this decision really had nothing to do with [their legacy system] in mind ... Our practitioners are very happy with [our legacy system] currently.' ... One respondent stated from past experience, 'Our past implementation [of the legacy system] was a painful transition. [We] had to force some people to fully use the electronic system.'"
Study Design
Pre-postintervention (no control group)
Study Participants
Eleven practice managers and 12 medical directors participated. Nine practice leaders were from five EHR based practices, and 14 practice leaders from seven paper-based practices.