Review
School of Business, Maynooth University, Kildare, Ireland
Corresponding Author:
Harriet Finnegan, MSc
School of Business
Maynooth University
3rd Floor TSI Building
Maynooth
Kildare, W23 X04D
Ireland
Phone: 353 17083609
Email: harriet.finnegan.2017@mumail.ie
Abstract
Background: Electronic health record (EHR) systems have undergone substantial evolution over the past 25 years, transitioning from rudimentary digital repositories to sophisticated tools that are integral to modern health care delivery. These systems have the potential to increase efficiency and improve patient care. However, for these systems to reach their potential, we need to understand how the process of EHR implementation works.
Objective: This scoping review aimed to examine the implementation process of EHRs from 1999 to 2024 and to articulate process-focused recommendations for future EHR implementations that build on this history of EHR research.
Methods: We conducted a scoping literature review following a systematic methodological framework. A total of 5 databases were selected from the disciplines of medicine and business: EBSCO, PubMed, Embase, IEEE Explore, and Scopus. The search included studies published from 1999 to 2024 that addressed the process of implementing an EHR. Keywords included “EHR,” “EHRS,” “Electronic Health Record*,” “EMR,” “EMRS,” “Electronic Medical Record*,” “implemen*,” and “process.” The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. The selected literature was thematically coded using NVivo qualitative analysis software, with the results reported qualitatively.
Results: This review included 90 studies that described the process of EHR implementation in different settings. The studies identified key elements, such as the role of the government and vendors, the importance of communication and relationships, the provision of training and support, and the implementation approach and cost. Four process-related categories emerged from these results: compliance processes, collaboration processes, competence-development processes, and process costs.
Conclusions: Although EHRs hold immense promise in improving patient care, enhancing research capabilities, and optimizing health care efficiency, there is a pressing need to examine the actual implementation process to understand how to approach implementation. Our findings offer 7 process-focused recommendations for EHR implementation formed from analysis of the selected literature.
doi:10.2196/60077
Keywords
Introduction
Background
Over the past 25 years, electronic health record (EHR) systems have undergone remarkable development, becoming an important element of modern health care [Tripathi M. EHR evolution: policy and legislation forces changing the EHR. J AHIMA. Oct 2012;83(10):24-9; quiz 30. [Medline]1]. Since their inception in the late 20th century, EHRs have advanced substantially, propelled by both technological innovations and critical policy reforms [Doyle-Lindrud S. The evolution of the electronic health record. CJON. Apr 1, 2015;19(2):153-154. [CrossRef]2]. Key legislation, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, was instrumental in accelerating the widespread adoption of EHRs, solidifying their role in enhancing health care delivery. Today, EHRs are indispensable for improving patient safety, improving operational efficiency, and ensuring that vital patient information is securely stored and easily accessible across health care settings [Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. May 2011;4:47-55. [FREE Full text] [CrossRef] [Medline]3].
Research to date has examined some of the key pre-implementation indicators of EHR adoption and success. Studies have revealed how certain organizational characteristics are likely to predict success, such as the size of the organization [Abramson EL, McGinnis S, Moore J, Kaushal R, HITEC Investigators. A statewide assessment of electronic health record adoption and health information exchange among nursing homes. Health Serv Res. Mar 2014;49(1 Pt 2):361-372. [FREE Full text] [CrossRef] [Medline]4,DesRoches CM, Worzala C, Joshi MS, Kralovec PD, Jha AK. Small, nonteaching, and rural hospitals continue to be slow in adopting electronic health record systems. Health Aff (Millwood). May 2012;31(5):1092-1099. [FREE Full text] [CrossRef] [Medline]5] and where it is located [Kruse CS, DeShazo J, Kim F, Fulton L. Factors associated with adoption of health information technology: a conceptual model based on a systematic review. JMIR Med Inform. May 23, 2014;2(1):e9. [FREE Full text] [CrossRef] [Medline]6,Jones EB, Furukawa MF. Adoption and use of electronic health records among federally qualified health centers grew substantially during 2010-12. Health Aff (Millwood). Jul 2014;33(7):1254-1261. [CrossRef] [Medline]7]. Other research has provided important details on postimplementation evaluations by users. These evaluations may include an increase or a decrease in the difficulty of tasks for the physician [Price C, Kwok ESH, Cheung WJ, Thiruganasambandamoorthy V, Clapham G, Nemnom M, et al. Physician experience with the Epic electronic health record (EHR) system: longitudinal findings from an emergency department implementation. CJEM. Oct 25, 2022;24(6):630-635. [CrossRef] [Medline]8], the impact on patient care [Sieck CJ, Pearl N, Bright TJ, Yen P. A qualitative study of physician perspectives on adaptation to electronic health records. BMC Med Inform Decis Mak. Mar 10, 2020;20(1):25. [FREE Full text] [CrossRef] [Medline]9], and effects on privacy and security [Mensah NK, Adzakpah G, Kissi J, Abdulai K, Taylor-Abdulai H, Johnson SB, et al. Health professionals' perceptions of electronic health records system: a mixed method study in Ghana. BMC Med Inform Decis Mak. Oct 16, 2024;24(1):254. [FREE Full text] [CrossRef] [Medline]10].
There is an extensive body of literature reviews published over the past 2 decades that explore the success factors and challenges associated with EHR implementation [Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: an evaluation of information system impact and contingency factors. Int J Med Inform. Dec 2014;83(11):779-796. [CrossRef] [Medline]11-Fennelly O, Cunningham C, Grogan L, Cronin H, O'Shea C, Roche M, et al. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. Dec 2020;144:104281. [FREE Full text] [CrossRef] [Medline]20]. This has substantially and importantly improved our understanding of those factors that must be considered when planning EHR implementation. Fennelly et al [Fennelly O, Cunningham C, Grogan L, Cronin H, O'Shea C, Roche M, et al. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. Dec 2020;144:104281. [FREE Full text] [CrossRef] [Medline]20], for example, identified 15 interlinked organizational, human, and technological factors that affect successful EHR implementation across primary, secondary, and long-term care settings. Our study built on this body of work by returning to the source literature with a process focus—digging beneath the success factors and challenges to examine the underpinning processes of EHR implementation. A process focus allows us to examine the connections between the factors already identified, unveiling new aspects, such as flow, activity, and temporality [Langley A, Smallman C, Tsoukas H, Van de Ven AH. Process studies of change in organization and management: unveiling temporality, activity, and flow. AMJ. Feb 2013;56(1):1-13. [CrossRef]21]. We, therefore, foregrounded and synthesized those papers that center on this vital process of implementing an EHR rather than delving into the technical intricacies of EHR technology itself.
Defining an EHR
The World Health Organization defines the EHR as “a longitudinal record of patient health information generated by one or more encounters in any care delivery setting” [World Health Organization. Electronic Health Records: Manual for Developing Countries. Geneva, Switzerland. World Health Organization; 2006. 22]. These records may include details such as demographics, progress notes, vital signs, medications, immunizations, lab results, and radiology reports, which all provide a comprehensive view of a patient’s health. Similarly, the Centers for Medicare and Medicaid Services (CMS) emphasizes that EHRs play a crucial role in helping health care providers maintain accurate and up-to-date patient data over time, ensuring that key clinical and administrative information is easily accessible and securely shared among authorized users [E-health and health information technology. Centers for Medicare & Medicaid Services. URL: https://www.cms.gov/priorities/key-initiatives/e-health/records [accessed 2024-10-01] 23].
Electronic medical records (EMRs), in contrast, are records created by practitioners for specific encounters, examples of which may be hospital visits or the use of facilities within ambulatory environments. Finally, a personal health record (PHR) is data controlled by the patient through the use of an electronic application that they are able to provide to their health practitioners. PHRs support patient-centered health care by making medical records and other relevant information accessible to patients, assisting patients in health self-management [Archer N, Fevrier-Thomas U, Lokker C, McKibbon KA, Straus SE. Personal health records: a scoping review. J Am Med Inform Assoc. Jul 2011;18(4):515-522. [FREE Full text] [CrossRef] [Medline]24]. We focused exclusively on EHRs rather than EMRs or PHRs. The scope of EHRs is generally larger than that of EMRs or PHRs. They require a broad range of data types and need to be able to connect these across systems, whereas EMRs are generally confined to an individual practice [Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in U.S. primary care. J Am Med Inform Assoc. 2003;10(1):1-10. [FREE Full text] [CrossRef] [Medline]25], limiting their scope, and PHRs are generally subject to personal management [Roehrs A, da Costa CA, Righi RDR, de Oliveira KSF. Personal health records: a systematic literature review. J Med Internet Res. Jan 06, 2017;19(1):e13. [FREE Full text] [CrossRef] [Medline]26]. This makes them less complex, and therefore less interesting from a research perspective, than EHRs. EHRs require higher levels of interoperability, regulatory challenges, stakeholder involvement, and cost and time investment than EMRs or PHRs, making them the ideal focus of this research.
Although the terms “EHR” and “EMR” are conceptually distinct, they are often used interchangeably in the literature. We recognize that the definitions we used for EHRs and EMRs in our review are not universally observed, and the terminology used in the literature and in practice often reflects the contexts in which these systems are implemented rather than the strict definitional boundaries placed upon them. In instances where studies, such as Felt-Lisk et al [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27], have examined systems referred to as EHRs but may have operationally aligned with our definition of EMRs, we opted for a more inclusive approach. This definitional ambiguity may mean that some of our recommendations may equally apply to systems labeled as EMRs rather than EHRs. Addressing this overlap is essential for advancing a more unified understanding of electronic records in health care; however, it was not the purpose of this research.
Implementation Process
Rather than the broader issue of EHR adoption, which relates to the widespread acceptance and use of the technology across health care settings, our focus was on implementation as the practical, often complex, process of integrating EHR technology into health care environments. Adoption is the “phase of investigation, research, consideration and decision making in order to introduce a new innovation into the organization” [Andriessen JHE. Innovation and implementation. In: Working with Groupware. Computer Supported Cooperative Work. London, UK. Springer; 2003:79-93.28,Bouwman H, van DWL, van DHB. Information and Communication Technology in Organizations: Adoption, Implementation, Use and Effects. London, UK. Sage; 2005. 29]. Implementation is the “phase of internal strategy formation, project definition and activities in which an adopted application is introduced within the organization, with the aim of removing reservations and stimulating the optimum use of the application” [Bouwman H, van DWL, van DHB. Information and Communication Technology in Organizations: Adoption, Implementation, Use and Effects. London, UK. Sage; 2005. 29]. Although adoption can occur both prior to and after implementation, these terms describe separate, distinct actions. We discussed EHRs in terms of the process of implementation, as defined by Bouwman et al [Bouwman H, van DWL, van DHB. Information and Communication Technology in Organizations: Adoption, Implementation, Use and Effects. London, UK. Sage; 2005. 29].
Study Focus
This scoping review examined the EHR implementation process over the past 25 years. The paper presented a qualitative thematic analysis of 90 relevant academic papers describing the EHR implementation process. Our review of 25 years’ worth of EHR implementation processes ultimately offers some advice and hope for more effective EHR implementations and those policies that support them.
Methods
Overview
A scoping review was conducted according to the 5-stage framework by Arksey and O’Malley [Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. Feb 2005;8(1):19-32. [CrossRef]30]. Results were reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist ( PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.Multimedia Appendix 1
Stage 1: Identifying the Research Question
Our research question was as follows: What have we learned about the process of implementing EHRs over the past 25 years?
Stage 2: Identifying Relevant Studies
A systematic literature search was conducted across 5 databases to identify all relevant literature: EBSCO, PubMed, EMBASE, IEEE Explore, and Scopus. The following specific keywords were used in the search strategy: (EHR OR EHRS OR Electronic Health Record* OR EMR OR EMRS OR Electronic Medical Record*) AND implemen* AND process (all in abstract). Detailed search strategies are provided in Search terms and search strategy for the scoping review.Multimedia Appendix 2
Inclusion Criteria
Studies meeting the following inclusion criteria were included: (1) published from January 1999 to August 2024, (2) peer reviewed, (3) journal papers, (4) published in English, and (5) mentioned the implementation process of EHRs.
Exclusion Criteria
Studies meeting the following criteria were excluded: (1) focused purely on the aftermath of implementation; (2) did not discuss the implementation process; (3) did not clearly report methods; (4) nonempirical; (5) not published in a peer-reviewed journal; (6) letters to the editor, editorials, or essays; (7) gray literature and review papers; and (8) discussed single-location EMRs.
Stage 3: Study Selection
All citations were uploaded to Covidence, a web-based research tool used by researchers to collaborate and organize citations in systematic reviews. Duplicates were removed automatically by the software and manually by both authors. Both authors screened all 4454 remaining papers by title and abstract and 226 papers by full text. Both authors also reviewed any disagreements before proceeding to the next stage of screening. This was done at each stage of screening to ensure consistency between decisions. Any disagreements were resolved by both authors discussing the eligibility of the paper in relation to the research focus and the agreed-upon inclusion and exclusion criteria until reaching consensus.
Stage 4: Charting the Data
Data were extracted by the first author using Microsoft Excel, including the following details: author(s)/publication year, country of origin, aim(s)/purpose, study design, type of organization, study population/sample size, record type, and methods.
Stage 5: Collating, Summarizing, and Reporting Results
After reviewing all full texts of the eligible studies, the first author loaded the remaining 90 full texts into NVivo, a qualitative data analysis software program. This software was used to manually organize the texts and facilitate the thematic coding of the data. All 90 full texts were then thematically coded by the first author. The second author thematically coded a subset of 10 (11.1%) full texts. Both authors then met to discuss any differences in coding decisions. This was carried out to ensure intercoder reliability.
Results
Sample Characteristics
The paper-screening process is illustrated in detail in Characteristics of the included studies.Figure 1, while the distribution of the selected studies by year of publication is shown in
Figure 2. Among the 90 papers, some discussed more than 1 country in their study. This included 37 (41.1%) studies conducted in the United States, 11 (12.2%) in England, 6 (6.7%) in Australia, 5 (5.6%) in Germany, 5 (5.6%) in Denmark, 3 (3.3%) in the Netherlands, 3 (3.3%) in Italy, 3 (3.3%) in Canada, 3 (3.3%) in Norway, 2 (2.2%) in Singapore, 2 (2.2%) in Kenya, 2 (2.2%) in the United Kingdom, and the remaining countries mentioned in only 1 (1.1%) study each. The majority of studies (n=59, 65.6%) were qualitative, while the remainder (n=19, 21.1%) were quantitative or used mixed methods (n=12, 13.3%). The selected papers begin in 1999 with 1 publication. Examining these figures showed initial inactivity on the topic, followed by steady growth starting in 2008 and peaking in 2017, with a slight decline in recent years. The peak years from 2014 to 2017 suggest a strong research interest during this time. Recently, from 2019 to 2024, there seemed to be a stabilization in research output, with around 4 publications annually. The main characteristics of the included studies are presented in
Multimedia Appendix 3


During the thematic coding process, sections of text within each paper were allocated to specific codes rather than entire papers being allocated to one code. As a result, multiple different codes may have appeared in one paper, as can be seen in the coding distribution table ( Coding structure of selected data.Table 1). The full coding structure is provided in
Multimedia Appendix 4
Theme and codes | Studies, n (%) | References | |||
Compliance | |||||
Government | 29 (32.2) | [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27,Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31-Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation. BMJ. Oct 01, 2010;341(sep01 3):c4564-c4564. [FREE Full text] [CrossRef] [Medline]58] | |||
Policy | 21 (23.3) | [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31,Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35,Currie W, Finnegan D. The policy-practice nexus of electronic health records adoption in the UK NHS. J Enterp Inf Manag. 2011;24:146-170. [CrossRef]37-Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41,Garrety K, McLoughlin I, Dalley A, Wilson R, Yu P. National electronic health record systems as 'wicked projects': the Australian experience. Inf Polity. Dec 22, 2016;21(4):367-381. [CrossRef]44,Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ. Dec 16, 2010;341:c5814. [FREE Full text] [CrossRef] [Medline]46,Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48,Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49,Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52,Cacciatore F, Bitonti A, Sgueo G. Interest groups and the implementation of electronic health records in the Italian NRRP, between policy and politics. Contemp Ital Politics. Dec 04, 2023;16(1):21-38. [CrossRef]55,Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation. BMJ. Oct 01, 2010;341(sep01 3):c4564-c4564. [FREE Full text] [CrossRef] [Medline]58-van Offenbeek MA, Vos JF, Boonstra A. Understanding variation in subunit adoption of electronic health records: facilitating and constraining configurations of critical dependencies. Eur J Inf Syst. Jun 25, 2023;33(2):221-243. [CrossRef]65] | |||
Regulations | 10 (11.2) | [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31,Boonstra A, van Offenbeek MAG, Vos JFJ. Tension awareness of stakeholders in large technology projects: a duality perspective. Project Manag J. Feb 01, 2017;48(1):19-36. [CrossRef]34,Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36,Cacciatore F, Bitonti A, Sgueo G. Interest groups and the implementation of electronic health records in the Italian NRRP, between policy and politics. Contemp Ital Politics. Dec 04, 2023;16(1):21-38. [CrossRef]55,Pohlmann S, Kunz A, Ose D, Winkler EC, Brandner A, Poss-Doering R, et al. Digitalizing health services by implementing a personal electronic health record in Germany: qualitative analysis of fundamental prerequisites from the perspective of selected experts. J Med Internet Res. Jan 29, 2020;22(1):e15102. [FREE Full text] [CrossRef] [Medline]62,Rau E, Tischendorf T, Mitzscherlich B. Implementation of the electronic health record in the German healthcare system: an assessment of the current status and future development perspectives considering the potentials of health data utilisation by representatives of different stakeholder groups. Front Health Serv. May 10, 2024;4:1370759. [FREE Full text] [CrossRef] [Medline]63,van Offenbeek MA, Vos JF, Boonstra A. Understanding variation in subunit adoption of electronic health records: facilitating and constraining configurations of critical dependencies. Eur J Inf Syst. Jun 25, 2023;33(2):221-243. [CrossRef]65-van Offenbeek MA, Vos JF. An integrative framework for managing project issues across stakeholder groups. Int J Project Manag. Jan 2016;34(1):44-57. [CrossRef]68] | |||
Vendors | 20 (22.2) | [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27,Currie W, Finnegan D. The policy-practice nexus of electronic health records adoption in the UK NHS. J Enterp Inf Manag. 2011;24:146-170. [CrossRef]37,Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38,Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49,Tobler N, Colvin J, Rawlins NW. Longitudinal analysis and coping model of user adaptation. J Comp Inf Syst. Jul 22, 2016;57(2):97-105. [CrossRef]53,Crowley K, Mishra A, Cruz-Cano R, Gold R, Kleinman D, Agarwal R. Electronic health record implementation findings at a large, suburban health and human services department. J Public Health Manag Pract. 2019;25(1):E11-E16. [FREE Full text] [CrossRef] [Medline]59,Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60,Mbwambo E, Mandari H. Acceptance of interoperable electronic health record (EHRs) systems: a Tanzanian e-health perspective. J Int Technol Inf Manag. Jan 01, 2023;32(1):96-121. [CrossRef]67,Carayon P, Smith P, Hundt AS, Kuruchittham V, Li Q. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behav Inf Technol. Jan 2009;28(1):5-20. [CrossRef]69-Weston C, Wells-Beede E, Salazar A, Poston D, Brown S, Hare M, et al. Patient-centered care through nurse practitioner-led integrated behavioral health: a case study. Public Health Rep. May 25, 2023;138(1_suppl):36S-41S. [FREE Full text] [CrossRef] [Medline]80] | |||
Collaboration | |||||
Communication | 40 (44.4) | [Barrett AK, Stephens KK. The pivotal role of change appropriation in the implementation of health care technology. Manag Commun Q. Dec 18, 2016;31(2):163-193. [CrossRef]32-Boonstra A, van Offenbeek MAG, Vos JFJ. Tension awareness of stakeholders in large technology projects: a duality perspective. Project Manag J. Feb 01, 2017;48(1):19-36. [CrossRef]34,Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36-Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38,Deutsch E, Duftschmid G, Dorda W. Critical areas of national electronic health record programs—is our focus correct? Int J Med Inform. Mar 2010;79(3):211-222. [CrossRef] [Medline]40-Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42,Garrety K, McLoughlin I, Dalley A, Wilson R, Yu P. National electronic health record systems as 'wicked projects': the Australian experience. Inf Polity. Dec 22, 2016;21(4):367-381. [CrossRef]44-Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ. Dec 16, 2010;341:c5814. [FREE Full text] [CrossRef] [Medline]46,Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49-Klecun E, Zhou Y, Kankanhalli A, Wee YH, Hibberd R. The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: a tale of two countries. J Inf Technol. Mar 27, 2019;34(4):292-332. [CrossRef]51,Crowley K, Mishra A, Cruz-Cano R, Gold R, Kleinman D, Agarwal R. Electronic health record implementation findings at a large, suburban health and human services department. J Public Health Manag Pract. 2019;25(1):E11-E16. [FREE Full text] [CrossRef] [Medline]59-Faiella A, Casper KA, Bible L, Seifert J. Implementation and use of an electronic health record in a charitable community pharmacy. J Am Pharm Assoc (2003). 2019;59(2S):S110-S117. [CrossRef] [Medline]61,Rau E, Tischendorf T, Mitzscherlich B. Implementation of the electronic health record in the German healthcare system: an assessment of the current status and future development perspectives considering the potentials of health data utilisation by representatives of different stakeholder groups. Front Health Serv. May 10, 2024;4:1370759. [FREE Full text] [CrossRef] [Medline]63,Brokel JM, Harrison MI. Redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf. Mar 2009;35(2):82-92. [CrossRef] [Medline]66,van Offenbeek MA, Vos JF. An integrative framework for managing project issues across stakeholder groups. Int J Project Manag. Jan 2016;34(1):44-57. [CrossRef]68,Collins S, Alexander D, Moss J. Nursing domain of CI governance: recommendations for health IT adoption and optimization. J Am Med Inform Assoc. May 2015;22(3):697-706. [CrossRef] [Medline]70,Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. CAH to CAH. Appl Clin Inform. Dec 20, 2017;05(01):92-117. [CrossRef]71,Hertzum M, Ellingsen G, Melby L. Drivers of expectations: why are Norwegian general practitioners skeptical of a prospective electronic health record? Health Inform J. Jan 13, 2021;27(1):1460458220987298. [FREE Full text] [CrossRef] [Medline]74-McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76,Scott JT, Rundall TG, Vogt TM, Hsu J. Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study. BMJ. Dec 03, 2005;331(7528):1313-1316. [FREE Full text] [CrossRef] [Medline]78,Sidek YH, Martins JT. Perceived critical success factors of electronic health record system implementation in a dental clinic context: an organisational management perspective. Int J Med Inform. Dec 2017;107:88-100. [FREE Full text] [CrossRef] [Medline]79,Boswell RA. Implementing electronic health records: implications for HR professionals. Strateg HR Rev. 2013;12(5):262-268. [CrossRef]81-Boonstra A, van Offenbeek MA. Shaping a buyer's software selection process through tendering legislation. Inf Syst J. Dec 14, 2017;28(5):905-928. [CrossRef]92] | |||
Relationships | 30 (33.3) | [Barrett AK, Stephens KK. The pivotal role of change appropriation in the implementation of health care technology. Manag Commun Q. Dec 18, 2016;31(2):163-193. [CrossRef]32-Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36,Deutsch E, Duftschmid G, Dorda W. Critical areas of national electronic health record programs—is our focus correct? Int J Med Inform. Mar 2010;79(3):211-222. [CrossRef] [Medline]40,Garrety K, McLoughlin I, Dalley A, Wilson R, Yu P. National electronic health record systems as 'wicked projects': the Australian experience. Inf Polity. Dec 22, 2016;21(4):367-381. [CrossRef]44,Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48-Kang'a SG, Muthee VM, Liku N, Too D, Puttkammer N. People, process and technology: strategies for assuring sustainable implementation of EMRs at public-sector health facilities in Kenya. AMIA Annu Symp Proc. 2016;2016:677-685. [FREE Full text] [Medline]50,Standing C, Cripps H. Critical success factors in the implementation of electronic health records: a two-case comparison. Syst Res. Aug 30, 2013;32(1):75-85. [CrossRef]57,Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60,van Offenbeek MA, Vos JF, Boonstra A. Understanding variation in subunit adoption of electronic health records: facilitating and constraining configurations of critical dependencies. Eur J Inf Syst. Jun 25, 2023;33(2):221-243. [CrossRef]65,Brokel JM, Harrison MI. Redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf. Mar 2009;35(2):82-92. [CrossRef] [Medline]66,van Offenbeek MA, Vos JF. An integrative framework for managing project issues across stakeholder groups. Int J Project Manag. Jan 2016;34(1):44-57. [CrossRef]68-Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. CAH to CAH. Appl Clin Inform. Dec 20, 2017;05(01):92-117. [CrossRef]71,McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76,Boswell RA. Implementing electronic health records: implications for HR professionals. Strateg HR Rev. 2013;12(5):262-268. [CrossRef]81,Kiepek W, Sengstack PP. An evaluation of system end-user support during implementation of an electronic health record using the model for improvement framework. Appl Clin Inform. Oct 18, 2019;10(5):964-971. [FREE Full text] [CrossRef] [Medline]84,Knight AW, Szucs C, Dhillon M, Lembke T, Mitchell C. The eCollaborative: using a quality improvement collaborative to implement the National eHealth Record System in Australian primary care practices. Int J Qual Health Care. Aug 12, 2014;26(4):411-417. [FREE Full text] [CrossRef] [Medline]85,Takian A, Sheikh A, Barber N. Organizational learning in the implementation and adoption of national electronic health records: case studies of two hospitals participating in the National Programme for Information Technology in England. Health Inform J. Oct 02, 2014;20(3):199-212. [FREE Full text] [CrossRef] [Medline]89,Yung A. Adoption of Electronic Health Record System in Community-Based Physiotherapy Clinics: A Pilot Case Study. Stud Health Technol Inform. 2017;234:395-400. [Medline]91-Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med. Jul 28, 2008;23(6):755-761. [FREE Full text] [CrossRef] [Medline]97] | |||
Competence | |||||
Training | 44 (48.9) | [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31,Bogaert P, Verschuuren M, Van Oyen H, van Oers H. Identifying common enablers and barriers in European health information systems. Health Policy. Dec 2021;125(12):1517-1526. [FREE Full text] [CrossRef] [Medline]33,Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38-Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42,Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ. Dec 16, 2010;341:c5814. [FREE Full text] [CrossRef] [Medline]46,Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48,Kang'a SG, Muthee VM, Liku N, Too D, Puttkammer N. People, process and technology: strategies for assuring sustainable implementation of EMRs at public-sector health facilities in Kenya. AMIA Annu Symp Proc. 2016;2016:677-685. [FREE Full text] [Medline]50,Tobler N, Colvin J, Rawlins NW. Longitudinal analysis and coping model of user adaptation. J Comp Inf Syst. Jul 22, 2016;57(2):97-105. [CrossRef]53,Vadillo PC, Rojo ES, Garces A, Checton MG. Maximizing healthcare professionals' use of new computer technologies in a small, urban hospital's critical care unit. J Healthc Manag. 2016;61(5):352-362. [CrossRef]54,Crowley K, Mishra A, Cruz-Cano R, Gold R, Kleinman D, Agarwal R. Electronic health record implementation findings at a large, suburban health and human services department. J Public Health Manag Pract. 2019;25(1):E11-E16. [FREE Full text] [CrossRef] [Medline]59-Faiella A, Casper KA, Bible L, Seifert J. Implementation and use of an electronic health record in a charitable community pharmacy. J Am Pharm Assoc (2003). 2019;59(2S):S110-S117. [CrossRef] [Medline]61,Rau E, Tischendorf T, Mitzscherlich B. Implementation of the electronic health record in the German healthcare system: an assessment of the current status and future development perspectives considering the potentials of health data utilisation by representatives of different stakeholder groups. Front Health Serv. May 10, 2024;4:1370759. [FREE Full text] [CrossRef] [Medline]63,Strong D, Volkoff O, Johnson S, Pelletier L, Tulu B, Bar-On I, et al. A theory of organization-EHR affordance actualization. JAIS. Feb 2014;15(2):53-85. [CrossRef]64,Brokel JM, Harrison MI. Redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf. Mar 2009;35(2):82-92. [CrossRef] [Medline]66-Collins S, Alexander D, Moss J. Nursing domain of CI governance: recommendations for health IT adoption and optimization. J Am Med Inform Assoc. May 2015;22(3):697-706. [CrossRef] [Medline]70,McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76,Noblin A, Cortelyou-Ward K, Cantiello J, Breyer T, Oliveira L, Dangiolo M, et al. EHR implementation in a new clinic: a case study of clinician perceptions. J Med Syst. Aug 2013;37(4):9955. [CrossRef] [Medline]77,Sidek YH, Martins JT. Perceived critical success factors of electronic health record system implementation in a dental clinic context: an organisational management perspective. Int J Med Inform. Dec 2017;107:88-100. [FREE Full text] [CrossRef] [Medline]79,Boswell RA. Implementing electronic health records: implications for HR professionals. Strateg HR Rev. 2013;12(5):262-268. [CrossRef]81-Gross AH, Leib RK, Tonachel A, Tonachel R, Bowers DM, Burnard RA, et al. Teamwork and electronic health record implementation: a case study of preserving effective communication and mutual trust in a changing environment. J Oncol Pract. Dec 2016;12(11):1075-1083. [CrossRef] [Medline]83,Martin M, Petros M, Welter C. Exploratory case study of barriers and facilitators associated with the pilot implementation of a new electronic healthcare record in the military. Mil Med. Mar 28, 2022;187(3-4):e486-e492. [FREE Full text] [CrossRef] [Medline]86,Takian A, Sheikh A, Barber N. Organizational learning in the implementation and adoption of national electronic health records: case studies of two hospitals participating in the National Programme for Information Technology in England. Health Inform J. Oct 02, 2014;20(3):199-212. [FREE Full text] [CrossRef] [Medline]89,Threatt T, Pirtle C, Dzwonkowski J, Johnson K. Using a custom mobile application for change management in an electronic health record implementation. JAMIA Open. May 2020;3(1):37-43. [FREE Full text] [CrossRef] [Medline]90,Banas CA, Erskine AR, Sun S, Retchin SM. Phased implementation of electronic health records through an office of clinical transformation. J Am Med Inform Assoc. Sep 01, 2011;18(5):721-725. [FREE Full text] [CrossRef] [Medline]94-Trocin C, Lee G, Bernardi R, Sarker S. How do unintended consequences emerge from EHR implementation? An affordance perspective. Inf Syst J. Apr 23, 2024;35(1):39-70. [CrossRef]106] | |||
Support | 35 (38.9) | [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27,Barrett AK, Stephens KK. The pivotal role of change appropriation in the implementation of health care technology. Manag Commun Q. Dec 18, 2016;31(2):163-193. [CrossRef]32,Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36,deRiel E, Puttkammer N, Hyppolite N, Diallo J, Wagner S, Honoré JG, et al. Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti. Health Policy Plan. Mar 01, 2018;33(2):237-246. [CrossRef] [Medline]39,Deutsch E, Duftschmid G, Dorda W. Critical areas of national electronic health record programs—is our focus correct? Int J Med Inform. Mar 2010;79(3):211-222. [CrossRef] [Medline]40,Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42,Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption of electronic health records and information systems. Health Aff (Millwood). 2005;24(5):1323-1333. [FREE Full text] [CrossRef] [Medline]43,Greenhalgh T, Stramer K, Bratan T, Byrne E, Mohammad Y, Russell J. Introduction of shared electronic records: multi-site case study using diffusion of innovation theory. BMJ. Oct 23, 2008;337:a1786. [FREE Full text] [CrossRef] [Medline]45,Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48,Kang'a SG, Muthee VM, Liku N, Too D, Puttkammer N. People, process and technology: strategies for assuring sustainable implementation of EMRs at public-sector health facilities in Kenya. AMIA Annu Symp Proc. 2016;2016:677-685. [FREE Full text] [Medline]50,Tobler N, Colvin J, Rawlins NW. Longitudinal analysis and coping model of user adaptation. J Comp Inf Syst. Jul 22, 2016;57(2):97-105. [CrossRef]53,Vadillo PC, Rojo ES, Garces A, Checton MG. Maximizing healthcare professionals' use of new computer technologies in a small, urban hospital's critical care unit. J Healthc Manag. 2016;61(5):352-362. [CrossRef]54,Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60,Brokel JM, Harrison MI. Redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf. Mar 2009;35(2):82-92. [CrossRef] [Medline]66,Mbwambo E, Mandari H. Acceptance of interoperable electronic health record (EHRs) systems: a Tanzanian e-health perspective. J Int Technol Inf Manag. Jan 01, 2023;32(1):96-121. [CrossRef]67,Carayon P, Smith P, Hundt AS, Kuruchittham V, Li Q. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behav Inf Technol. Jan 2009;28(1):5-20. [CrossRef]69-Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. CAH to CAH. Appl Clin Inform. Dec 20, 2017;05(01):92-117. [CrossRef]71,Hertzum M, Ellingsen G, Melby L. Drivers of expectations: why are Norwegian general practitioners skeptical of a prospective electronic health record? Health Inform J. Jan 13, 2021;27(1):1460458220987298. [FREE Full text] [CrossRef] [Medline]74-McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76,Sidek YH, Martins JT. Perceived critical success factors of electronic health record system implementation in a dental clinic context: an organisational management perspective. Int J Med Inform. Dec 2017;107:88-100. [FREE Full text] [CrossRef] [Medline]79,Boswell RA. Implementing electronic health records: implications for HR professionals. Strateg HR Rev. 2013;12(5):262-268. [CrossRef]81,Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999;44(6):440-54; discussion 454. [Medline]82,Kiepek W, Sengstack PP. An evaluation of system end-user support during implementation of an electronic health record using the model for improvement framework. Appl Clin Inform. Oct 18, 2019;10(5):964-971. [FREE Full text] [CrossRef] [Medline]84,Martin M, Petros M, Welter C. Exploratory case study of barriers and facilitators associated with the pilot implementation of a new electronic healthcare record in the military. Mil Med. Mar 28, 2022;187(3-4):e486-e492. [FREE Full text] [CrossRef] [Medline]86,Threatt T, Pirtle C, Dzwonkowski J, Johnson K. Using a custom mobile application for change management in an electronic health record implementation. JAMIA Open. May 2020;3(1):37-43. [FREE Full text] [CrossRef] [Medline]90,Boswell RA. A physician group's movement toward electronic health records: a case study using the transtheoretical model for organizational change. Consult Psychol J: Pract Res. Jun 2011;63(2):138-148. [CrossRef]95,Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med. Jul 28, 2008;23(6):755-761. [FREE Full text] [CrossRef] [Medline]97,Snowden A, Kolb H. Two years of unintended consequences: introducing an electronic health record system in a hospice in Scotland. J Clin Nurs. May 21, 2017;26(9-10):1414-1427. [FREE Full text] [CrossRef] [Medline]105-Marca G, Perez A, Blanco-Garcia MG, Miravalles E, Soley P, Ortiga B. The use of electronic health records in Spanish hospitals. Health Inf Manag. Oct 01, 2014;43(3):37-44. [CrossRef] [Medline]110] | |||
Cost | |||||
Cost | 41 (45.6) | [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27,Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31,Bogaert P, Verschuuren M, Van Oyen H, van Oers H. Identifying common enablers and barriers in European health information systems. Health Policy. Dec 2021;125(12):1517-1526. [FREE Full text] [CrossRef] [Medline]33,Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35-Deutsch E, Duftschmid G, Dorda W. Critical areas of national electronic health record programs—is our focus correct? Int J Med Inform. Mar 2010;79(3):211-222. [CrossRef] [Medline]40,Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42,Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption of electronic health records and information systems. Health Aff (Millwood). 2005;24(5):1323-1333. [FREE Full text] [CrossRef] [Medline]43,Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ. Dec 16, 2010;341:c5814. [FREE Full text] [CrossRef] [Medline]46,Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48-Kang'a SG, Muthee VM, Liku N, Too D, Puttkammer N. People, process and technology: strategies for assuring sustainable implementation of EMRs at public-sector health facilities in Kenya. AMIA Annu Symp Proc. 2016;2016:677-685. [FREE Full text] [Medline]50,Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52,Vadillo PC, Rojo ES, Garces A, Checton MG. Maximizing healthcare professionals' use of new computer technologies in a small, urban hospital's critical care unit. J Healthc Manag. 2016;61(5):352-362. [CrossRef]54,Maier CD, Frandsen F, Johansen W. Understanding the arena of smoldering crises: a longitudinal study of discursive struggles after implementing a new IT health care platform. JCOM. Sep 23, 2022;27(3):329-344. [CrossRef]56,Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60,Rau E, Tischendorf T, Mitzscherlich B. Implementation of the electronic health record in the German healthcare system: an assessment of the current status and future development perspectives considering the potentials of health data utilisation by representatives of different stakeholder groups. Front Health Serv. May 10, 2024;4:1370759. [FREE Full text] [CrossRef] [Medline]63,van Offenbeek MA, Vos JF, Boonstra A. Understanding variation in subunit adoption of electronic health records: facilitating and constraining configurations of critical dependencies. Eur J Inf Syst. Jun 25, 2023;33(2):221-243. [CrossRef]65,Brokel JM, Harrison MI. Redesigning care processes using an electronic health record: a system's experience. Jt Comm J Qual Patient Saf. Mar 2009;35(2):82-92. [CrossRef] [Medline]66,van Offenbeek MA, Vos JF. An integrative framework for managing project issues across stakeholder groups. Int J Project Manag. Jan 2016;34(1):44-57. [CrossRef]68,Carayon P, Smith P, Hundt AS, Kuruchittham V, Li Q. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behav Inf Technol. Jan 2009;28(1):5-20. [CrossRef]69,Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. CAH to CAH. Appl Clin Inform. Dec 20, 2017;05(01):92-117. [CrossRef]71,Ford EW, Menachemi N, Huerta TR, Yu F. Hospital IT adoption strategies associated with implementation success: implications for achieving meaningful use. J Healthc Manag. 2010;55(3):175-88; discussion 188. [Medline]72,Hertzum M, Ellingsen G, Cajander Å. Implementing large-scale electronic health records: experiences from implementations of Epic in Denmark and Finland. Int J Med Inform. Dec 2022;167:104868. [CrossRef] [Medline]75,Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999;44(6):440-54; discussion 454. [Medline]82,Pearce C, Bartlett J, Mcleod A, Eustace P, Amos R, Shearer M. Effectiveness of local support for the adoption of a national programme--a descriptive study. Inform Prim Care. 2014;21(4):171-178. [FREE Full text] [CrossRef] [Medline]88,Threatt T, Pirtle C, Dzwonkowski J, Johnson K. Using a custom mobile application for change management in an electronic health record implementation. JAMIA Open. May 2020;3(1):37-43. [FREE Full text] [CrossRef] [Medline]90,Boonstra A, van Offenbeek MA. Shaping a buyer's software selection process through tendering legislation. Inf Syst J. Dec 14, 2017;28(5):905-928. [CrossRef]92-Banas CA, Erskine AR, Sun S, Retchin SM. Phased implementation of electronic health records through an office of clinical transformation. J Am Med Inform Assoc. Sep 01, 2011;18(5):721-725. [FREE Full text] [CrossRef] [Medline]94,Takian A, Sheikh A, Barber N. We are bitter, but we are better off: case study of the implementation of an electronic health record system into a mental health hospital in England. BMC Health Serv Res. Dec 31, 2012;12(1):484. [FREE Full text] [CrossRef] [Medline]96,Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med. Jul 28, 2008;23(6):755-761. [FREE Full text] [CrossRef] [Medline]97,Trocin C, Lee G, Bernardi R, Sarker S. How do unintended consequences emerge from EHR implementation? An affordance perspective. Inf Syst J. Apr 23, 2024;35(1):39-70. [CrossRef]106,Palvia P, Jacks T, Brown W. Critical issues in EHR implementation: provider and vendor perspectives. Commun Assoc Inf Syst. 2015:36. [FREE Full text] [CrossRef]108,Marca G, Perez A, Blanco-Garcia MG, Miravalles E, Soley P, Ortiga B. The use of electronic health records in Spanish hospitals. Health Inf Manag. Oct 01, 2014;43(3):37-44. [CrossRef] [Medline]110-Gabriel MH, Jones EB, Samy L, King J. Progress and challenges: implementation and use of health information technology among critical-access hospitals. Health Aff (Millwood). Jul 2014;33(7):1262-1270. [CrossRef] [Medline]113] |
The Implementation Process
Overview
The 90 studies provide a broad overview of the process of EHR implementation over the past 25 years.
A process-based view considers time as a key element. EHR implementation is described by Boonstra et al [Boonstra A, van Offenbeek MAG, Vos JFJ. Tension awareness of stakeholders in large technology projects: a duality perspective. Project Manag J. Feb 01, 2017;48(1):19-36. [CrossRef]34] as a complex and time consuming process, and by Hernández-Ávila et al [Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48] as a gradual and often slow process. The main benefits of EHRs are likely to accrue in the long term, so it is important to envision them as long-term change management endeavors [Takian A, Sheikh A, Barber N. We are bitter, but we are better off: case study of the implementation of an electronic health record system into a mental health hospital in England. BMC Health Serv Res. Dec 31, 2012;12(1):484. [FREE Full text] [CrossRef] [Medline]96]. These long-term benefits may never be realized, however, where short-term time pressures jeopardize implementation. This may arise where there is limited time available to adapt the system to local conditions [Hariyati RTS, Hamid AY, Eryando T, Hasibuan ZA. Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia. Int J Healthc Manag. Jul 31, 2018;13(1):45-52. [CrossRef]98] or where the pace of implementation is being dictated by other ongoing projects [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49]. Deadlines imposed by external actors may also result in implementation timelines being rushed. For example, political considerations may frame procurement arrangements [Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52], or vendors might enforce tight deadlines [Hertzum M, Ellingsen G. The implementation of an electronic health record: comparing preparations for Epic in Norway with experiences from the UK and Denmark. Int J Med Inform. Oct 2019;129:312-317. [CrossRef] [Medline]73]. Diffusion processes require good planning and consume both time and resources [Marca G, Perez A, Blanco-Garcia MG, Miravalles E, Soley P, Ortiga B. The use of electronic health records in Spanish hospitals. Health Inf Manag. Oct 01, 2014;43(3):37-44. [CrossRef] [Medline]110]. Time looms large in our reviewed studies, justifying our process focus. There is a constant pressure of time in relation to the implementation [Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38], but the reality is that pre-existing day-to-day pressures may limit the pace of implementation [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27].
Four central process-related categories emerged from the thematic review: (1) compliance processes featured indirectly through references to the important role of the government, policy, regulations, and vendors; (2) collaboration processes centered on the work of managing these implementations through communication and relationships; (3) competence-building processes included discussions of training and support; and (4) process costs drew attention to areas of cost.
Compliance Processes in EHR Implementation
Our review suggested that compliance processes in EHR implementation center around the government, policy, regulations, and vendors. The literature referenced government-related processes in 29 (32.2%) papers. There were discussions of policy-related processes in 21 (23.3%) papers. Regulation-related processes were considered in 10 (11.1%) papers, and vendor-related processes were referenced throughout 20 (22.2%) papers.
Government-Related Compliance Processes
EHR implementation problems often arise at the national level rather than at regional or health service–specific levels. This is a result of the increased complexity of national implementation [Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38]. Nationwide implementation requires a huge change from stakeholders [Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42]. In a national project, practitioners operating in public and private domains require different engagement strategies to secure their buy-in [Klecun E, Zhou Y, Kankanhalli A, Wee YH, Hibberd R. The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: a tale of two countries. J Inf Technol. Mar 27, 2019;34(4):292-332. [CrossRef]51]. A national strategy is, therefore, needed for a national EHR implementation process [Marca G, Perez A, Blanco-Garcia MG, Miravalles E, Soley P, Ortiga B. The use of electronic health records in Spanish hospitals. Health Inf Manag. Oct 01, 2014;43(3):37-44. [CrossRef] [Medline]110]. National EHRs require adaptation with clinician practices nationwide to ensure workflow processes are consistent [Yung A. Adoption of Electronic Health Record System in Community-Based Physiotherapy Clinics: A Pilot Case Study. Stud Health Technol Inform. 2017;234:395-400. [Medline]91]. Further recommendations from the literature include changing from a top-down implementation model to increased involvement of local organizations in decision-making [Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35]. Planners need to ensure potentially unclear areas are clarified with program management and that clinicians are informed and consulted [Klecun E, Zhou Y, Kankanhalli A, Wee YH, Hibberd R. The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: a tale of two countries. J Inf Technol. Mar 27, 2019;34(4):292-332. [CrossRef]51]. National-level implementation is not just simple system installation; it is discovering ideas from private institutions and using them to drive best practices across the system nationwide [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49]. Bottom-up implementation is, however, time-consuming and may hinder future collaborations [Banas CA, Erskine AR, Sun S, Retchin SM. Phased implementation of electronic health records through an office of clinical transformation. J Am Med Inform Assoc. Sep 01, 2011;18(5):721-725. [FREE Full text] [CrossRef] [Medline]94], whereas the top-down nature of some projects contributes to a lack of organizational and user involvement in decision-making [Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52].
The role of the government in initiating and maintaining momentum around EHR implementation processes came through strongly from our review. Government leadership is considered a strategic advantage when the goal is the sustained enforcement of EHR initiatives [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31]. Mature EHR systems benefit from being well integrated into the national health-planning documents of the government [deRiel E, Puttkammer N, Hyppolite N, Diallo J, Wagner S, Honoré JG, et al. Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti. Health Policy Plan. Mar 01, 2018;33(2):237-246. [CrossRef] [Medline]39], while national reimbursement policies can increase EHR dissemination [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49]. To maintain momentum, government commitment must be both strong and continued and accompanied by political support [Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36]. eHealth experts are, therefore, generally in favor of a strong central solution for political regulation problems [Pohlmann S, Kunz A, Ose D, Winkler EC, Brandner A, Poss-Doering R, et al. Digitalizing health services by implementing a personal electronic health record in Germany: qualitative analysis of fundamental prerequisites from the perspective of selected experts. J Med Internet Res. Jan 29, 2020;22(1):e15102. [FREE Full text] [CrossRef] [Medline]62]. It is, however, not just the national government that matters. Support from the local government also plays a crucial role in terms of finances, provision of resources, and technical support [Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41]. Indeed, implementation processes suffer where they lack sufficient coordination with the local government [Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41]. However, strong national or local government policies mandating the use of specific eHealth solutions may support EHR implementation processes [Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41]. Excessive regulation may also hinder the long-term sustainability of EHR initiatives [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31].
Changes in the government may lead to having to modify an overall implementation process [Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35]. Shifts in the government strategy affect the power dynamics between national branches of large IT companies compared to national information and communication technology companies [Cacciatore F, Bitonti A, Sgueo G. Interest groups and the implementation of electronic health records in the Italian NRRP, between policy and politics. Contemp Ital Politics. Dec 04, 2023;16(1):21-38. [CrossRef]55]. A change in the government also has the potential to result in uncertainty about the future of national programs [Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52,Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation. BMJ. Oct 01, 2010;341(sep01 3):c4564-c4564. [FREE Full text] [CrossRef] [Medline]58]. It is, therefore, advisable for system evaluators to form close relationships with policy makers [Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35]. Alternatively, if there is a lack of a government-level information policy at the time of design and development, the sustainability of the EHR implementation is endangered [Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48].
The Role of Vendors
Governments are not, however, the only organizational actors who can manage or lead EHR compliance processes. Vendor organizations that have strong centralized administrative and medical structures are drivers of organizational policies and processes that are crucial to compliance [Strong D, Volkoff O, Johnson S, Pelletier L, Tulu B, Bar-On I, et al. A theory of organization-EHR affordance actualization. JAIS. Feb 2014;15(2):53-85. [CrossRef]64]. Indeed, in some instances, large private vendors may enter a market specifically to provide unified access to health care data [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49]. It is the process of compliance of large technology companies with uniform national standards and rules that enables EHR implementation in this instance [Cacciatore F, Bitonti A, Sgueo G. Interest groups and the implementation of electronic health records in the Italian NRRP, between policy and politics. Contemp Ital Politics. Dec 04, 2023;16(1):21-38. [CrossRef]55,Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60].
Vendor recommendations influence software choice processes [Carayon P, Smith P, Hundt AS, Kuruchittham V, Li Q. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behav Inf Technol. Jan 2009;28(1):5-20. [CrossRef]69]. EHR implementors cannot simply buy from the same vendor as their existing financial system and assume turnkey, seamless interoperability [Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. CAH to CAH. Appl Clin Inform. Dec 20, 2017;05(01):92-117. [CrossRef]71]. There are often limitations to existing vendor-based EHRs when compared with in-house systems, including autonomy of practice decisions at each hospital [Collins S, Alexander D, Moss J. Nursing domain of CI governance: recommendations for health IT adoption and optimization. J Am Med Inform Assoc. May 2015;22(3):697-706. [CrossRef] [Medline]70]. These limitations are also seen in difficult-to-assess EHR usability as a result of restrictive vendor license agreements [Crowley K, Mishra A, Cruz-Cano R, Gold R, Kleinman D, Agarwal R. Electronic health record implementation findings at a large, suburban health and human services department. J Public Health Manag Pract. 2019;25(1):E11-E16. [FREE Full text] [CrossRef] [Medline]59].
EHR vendors are generally at least partly responsible for the amount of training received by users [Carayon P, Smith P, Hundt AS, Kuruchittham V, Li Q. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behav Inf Technol. Jan 2009;28(1):5-20. [CrossRef]69] and sometimes also responsible for providing technical support [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27]. Indeed, vendors may use the provision of ongoing technical support as a form of training [Noblin A, Cortelyou-Ward K, Cantiello J, Breyer T, Oliveira L, Dangiolo M, et al. EHR implementation in a new clinic: a case study of clinician perceptions. J Med Syst. Aug 2013;37(4):9955. [CrossRef] [Medline]77]. Both peer and technical support may be issued from these vendors, which can help end-users optimize their use of the EHRs and solve issues [Mbwambo E, Mandari H. Acceptance of interoperable electronic health record (EHRs) systems: a Tanzanian e-health perspective. J Int Technol Inf Manag. Jan 01, 2023;32(1):96-121. [CrossRef]67]. Even large vendors may need to consider EHR adaptations for small practices as part of the sale of the EHR, ensuring that a person within the practice conducts training and adapts it to the specific needs of the practice rather than relying on training by IT specialists [Tobler N, Colvin J, Rawlins NW. Longitudinal analysis and coping model of user adaptation. J Comp Inf Syst. Jul 22, 2016;57(2):97-105. [CrossRef]53].
Collaboration Processes in EHR Implementation
Collaboration in the literature includes communication and relationships throughout the management of the implementation process. Communication was mentioned in 40 (44.4%) papers. Relationships were discussed in 30 (33.3%) papers.
Collaboration among team members is important [Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60], as is communicating clear expectations and guidelines [Faiella A, Casper KA, Bible L, Seifert J. Implementation and use of an electronic health record in a charitable community pharmacy. J Am Pharm Assoc (2003). 2019;59(2S):S110-S117. [CrossRef] [Medline]61]. Consistent, reliable communication fosters trust [Gross AH, Leib RK, Tonachel A, Tonachel R, Bowers DM, Burnard RA, et al. Teamwork and electronic health record implementation: a case study of preserving effective communication and mutual trust in a changing environment. J Oncol Pract. Dec 2016;12(11):1075-1083. [CrossRef] [Medline]83], and well-articulated visions are important for the management of expectations [Hertzum M, Ellingsen G, Melby L. Drivers of expectations: why are Norwegian general practitioners skeptical of a prospective electronic health record? Health Inform J. Jan 13, 2021;27(1):1460458220987298. [FREE Full text] [CrossRef] [Medline]74]. Strong communication practices are an enabler of successful implementation outcomes [Kiepek W, Sengstack PP. An evaluation of system end-user support during implementation of an electronic health record using the model for improvement framework. Appl Clin Inform. Oct 18, 2019;10(5):964-971. [FREE Full text] [CrossRef] [Medline]84]. However, a lack of communication during planning can cause issues [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49].
Collaborating facilitates successful EHR implementation [Boswell RA. A physician group's movement toward electronic health records: a case study using the transtheoretical model for organizational change. Consult Psychol J: Pract Res. Jun 2011;63(2):138-148. [CrossRef]95]. Cuccinello et al [Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36] illustrate this in their study of a vendor’s collaborative relationship with a health care department in Italy. Relationships with vendors build confidence within the organization and ensure strong external support [Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60]. Where, however, communication breaks down, it can jeopardize implementation processes [Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41]. Relationships between contractors and suppliers may become more impersonal and distant as a result [Boonstra A, van Offenbeek MAG, Vos JFJ. Tension awareness of stakeholders in large technology projects: a duality perspective. Project Manag J. Feb 01, 2017;48(1):19-36. [CrossRef]34]. Direct and close channels of communication between the implementer hospitals and software suppliers are, therefore, essential from the outset [Takian A, Sheikh A, Barber N. Organizational learning in the implementation and adoption of national electronic health records: case studies of two hospitals participating in the National Programme for Information Technology in England. Health Inform J. Oct 02, 2014;20(3):199-212. [FREE Full text] [CrossRef] [Medline]89]. Kiepek and Sengstack [Kiepek W, Sengstack PP. An evaluation of system end-user support during implementation of an electronic health record using the model for improvement framework. Appl Clin Inform. Oct 18, 2019;10(5):964-971. [FREE Full text] [CrossRef] [Medline]84] suggest an open and transparent relationship with external support from vendors, beginning with initial negotiations.
Competence-Building Processes in EHR Implementation
Competence building in the literature includes training and technical support. The literature referenced training in 44 (48.9%) papers. Support was discussed in 35 (38.9%) of the selected papers.
Training is necessary for successful EHR implementation [Boswell RA. A physician group's movement toward electronic health records: a case study using the transtheoretical model for organizational change. Consult Psychol J: Pract Res. Jun 2011;63(2):138-148. [CrossRef]95]. This training should provide practitioners with the skills necessary to operate the system, as well as the confidence to help them adapt to the new system [Hariyati RTS, Hamid AY, Eryando T, Hasibuan ZA. Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia. Int J Healthc Manag. Jul 31, 2018;13(1):45-52. [CrossRef]98]. Sufficient training for practitioners is associated with improved well-being [Heponiemi T, Gluschkoff K, Vehko T, Kaihlanen A, Saranto K, Nissinen S, et al. Electronic health record implementations and insufficient training endanger nurses' well-being: cross-sectional survey study. J Med Internet Res. Dec 23, 2021;23(12):e27096. [FREE Full text] [CrossRef] [Medline]100] and has a positive and substantial influence on perceived ease of use [Mbwambo E, Mandari H. Acceptance of interoperable electronic health record (EHRs) systems: a Tanzanian e-health perspective. J Int Technol Inf Manag. Jan 01, 2023;32(1):96-121. [CrossRef]67]. Hiring experts can help, for example, in providing technical support both during the implementation and afterward [Marca G, Perez A, Blanco-Garcia MG, Miravalles E, Soley P, Ortiga B. The use of electronic health records in Spanish hospitals. Health Inf Manag. Oct 01, 2014;43(3):37-44. [CrossRef] [Medline]110], and hiring clinical informaticists can help support EHR implementation and sustainment [Martin M, Petros M, Welter C. Exploratory case study of barriers and facilitators associated with the pilot implementation of a new electronic healthcare record in the military. Mil Med. Mar 28, 2022;187(3-4):e486-e492. [FREE Full text] [CrossRef] [Medline]86].
Issues surrounding training and implementation processes are numerous. These include a lack of resources for EHR training [Collins S, Alexander D, Moss J. Nursing domain of CI governance: recommendations for health IT adoption and optimization. J Am Med Inform Assoc. May 2015;22(3):697-706. [CrossRef] [Medline]70], the need to train medical personnel [Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38], a lack of training for smaller entities [Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38], ensuring sufficient time for staff training [Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41], providers and patients not receiving adequate support and training [Rau E, Tischendorf T, Mitzscherlich B. Implementation of the electronic health record in the German healthcare system: an assessment of the current status and future development perspectives considering the potentials of health data utilisation by representatives of different stakeholder groups. Front Health Serv. May 10, 2024;4:1370759. [FREE Full text] [CrossRef] [Medline]63], and a lack of appropriately specific training [Ser G, Robertson A, Sheikh A. A qualitative exploration of workarounds related to the implementation of national electronic health records in early adopter mental health hospitals. PLoS One. 2014;9(1):e77669. [FREE Full text] [CrossRef] [Medline]102]. The need for sufficient trained personnel is felt across all stages of an implementation process [deRiel E, Puttkammer N, Hyppolite N, Diallo J, Wagner S, Honoré JG, et al. Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti. Health Policy Plan. Mar 01, 2018;33(2):237-246. [CrossRef] [Medline]39]. Staff that are not trained to interact with an EHR can hinder implementation [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31,Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42]. Recommendations to enhance EHR training include ensuring that it occurs pre- and postimplementation on a continued cycle [Martin M, Petros M, Welter C. Exploratory case study of barriers and facilitators associated with the pilot implementation of a new electronic healthcare record in the military. Mil Med. Mar 28, 2022;187(3-4):e486-e492. [FREE Full text] [CrossRef] [Medline]86]. Decreased support is an additional issue [Collins S, Alexander D, Moss J. Nursing domain of CI governance: recommendations for health IT adoption and optimization. J Am Med Inform Assoc. May 2015;22(3):697-706. [CrossRef] [Medline]70], whether that be in relation to practitioner support [Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption of electronic health records and information systems. Health Aff (Millwood). 2005;24(5):1323-1333. [FREE Full text] [CrossRef] [Medline]43] or in determining the right type of IT support for successful implementation [Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med. Jul 28, 2008;23(6):755-761. [FREE Full text] [CrossRef] [Medline]97].
Process Costs in EHR Implementation
Cost considerations were shown to be an important part of the implementation process, with 41 (45.6%) papers making reference to cost. Adoption of appropriate processes is crucial regarding system development time and budget [Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42]. As such, successful implementation should have sustainable funding that aligns with a national strategy for eHealth [Evio BD, Bonito SR. Formative evaluation of the implementation of eHealth in the Philippines: a qualitative study. Acta Med Philipp. 2024;58(12):35-47. [CrossRef] [Medline]41]. Determining costs and measures of success is a vital part of project management, especially in pre-implementation [Palvia P, Jacks T, Brown W. Critical issues in EHR implementation: provider and vendor perspectives. Commun Assoc Inf Syst. 2015:36. [FREE Full text] [CrossRef]108]. The role of monetary incentives in this stage of the process is also an enabler [Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36]. One of the challenges of a national project is that funding sources depend largely on the government [Ghani MKA, Bali RK, Naguib RN, Marshall IM, Wickramasinghe NS. Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. IJEH. 2008;4(1):78. [CrossRef]31]. Implementing a system on a national scale is an extremely complex activity [Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52]. It is difficult to manage, costly to maintain, and hard to sustain [Takian A, Sheikh A, Barber N. Organizational learning in the implementation and adoption of national electronic health records: case studies of two hospitals participating in the National Programme for Information Technology in England. Health Inform J. Oct 02, 2014;20(3):199-212. [FREE Full text] [CrossRef] [Medline]89]. Financially, the most serious obstacle in implementing EHRs is the cost of electrification [Czerw A, Fronczak A, Witczak K, Juszczyk G. Implementation of electronic health records in Polish outpatient health care clinics - starting point, progress, problems, and forecasts. Ann Agric Environ Med. Jul 02, 2016;23(2):329-334. [FREE Full text] [CrossRef] [Medline]38]. Further customization also leads to increased maintenance costs [Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60]. The high upfront cost of EHRs for small practices is a major factor limiting their use [Felt-Lisk S, Johnson L, Fleming C, Shapiro R, Natzke B. Toward understanding EHR use in small physician practices. Health Care Financ Rev. 2010;31(1):11-22. [FREE Full text] [Medline]27]. Most hospitals report substantial financial challenges in EHR implementation and use, including EHR and broadband implementation costs and the limited availability of grants and loans to support EHR implementation and use [Gabriel MH, Jones EB, Samy L, King J. Progress and challenges: implementation and use of health information technology among critical-access hospitals. Health Aff (Millwood). Jul 2014;33(7):1262-1270. [CrossRef] [Medline]113]. A lack of capital resources can hinder the EHR implementation process [Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption of electronic health records and information systems. Health Aff (Millwood). 2005;24(5):1323-1333. [FREE Full text] [CrossRef] [Medline]43]. Other issues include inadequate capital for investment and maintenance costs [Marca G, Perez A, Blanco-Garcia MG, Miravalles E, Soley P, Ortiga B. The use of electronic health records in Spanish hospitals. Health Inf Manag. Oct 01, 2014;43(3):37-44. [CrossRef] [Medline]110], large-scale procurement being undertaken to save costs [Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals. BMJ. Oct 17, 2011;343(oct17 1):d6054-d6054. [FREE Full text] [CrossRef] [Medline]52], attempts to implement EHRs halting due to financial issues [Vadillo PC, Rojo ES, Garces A, Checton MG. Maximizing healthcare professionals' use of new computer technologies in a small, urban hospital's critical care unit. J Healthc Manag. 2016;61(5):352-362. [CrossRef]54], and the high costs of implementing a system [Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med. Jul 28, 2008;23(6):755-761. [FREE Full text] [CrossRef] [Medline]97].
Discussion
Principal Findings
This scoping review revealed 4 main areas for consideration in the EHR implementation process. These areas are compliance, collaboration, competence, and costs. Specific issues recurred in each area throughout the literature: the role of the government and the role of vendors in compliance processes, the importance of communication and relationships to facilitate collaboration processes, training and support to build competence; and the cost of financing throughout the implementation process. Many of the 19 interventions identified by Boonstra et al [Boonstra A, Versluis A, Vos JFJ. Implementing electronic health records in hospitals: a systematic literature review. BMC Health Serv Res. Oct 04, 2014;14(1):370. [FREE Full text] [CrossRef] [Medline]13], and the 15 factors identified by Fennelly et al [Fennelly O, Cunningham C, Grogan L, Cronin H, O'Shea C, Roche M, et al. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. Dec 2020;144:104281. [FREE Full text] [CrossRef] [Medline]20] pertaining to successful or effective implementation strategies featured within our findings. Rather than replicate the reviews of Fennelly et al [Fennelly O, Cunningham C, Grogan L, Cronin H, O'Shea C, Roche M, et al. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. Dec 2020;144:104281. [FREE Full text] [CrossRef] [Medline]20] or Boonstra et al [Boonstra A, Versluis A, Vos JFJ. Implementing electronic health records in hospitals: a systematic literature review. BMC Health Serv Res. Oct 04, 2014;14(1):370. [FREE Full text] [CrossRef] [Medline]13], however, we built on these to provide a focused exploration of the implementation process to complement the broader insights that these reviews offer. We built on these works to offer practical recommendations for use in the implementation process.
Our study and research question focused on the process of implementation of EHRs. The process of implementation deserves attention, especially when we consider that the implementation process influences implementation outcomes. Put differently, it is not just what system we implement, nor the recognition of challenges or facilitators, but also the process by which we navigate and manage these over time that ultimately decides how successful an EHR might be. There is, therefore, a need to understand how to approach these implementation processes in a way that is informed by previous implementations and the appropriate literature. To address this, we provide recommendations produced from our synthesis of the selected literature reviewed in this paper. Organizing our findings into compliance processes, collaboration processes, competence processes, and process costs allowed us to provide distinct actionable recommendations for stakeholders. Our recommendations emphasize implementation priorities in a way that facilitates targeted interventions. Our recommendations not only reaffirm established principles found in reviews, such as those by Boonstra et al [Boonstra A, Versluis A, Vos JFJ. Implementing electronic health records in hospitals: a systematic literature review. BMC Health Serv Res. Oct 04, 2014;14(1):370. [FREE Full text] [CrossRef] [Medline]13] and Fennelly et al [Fennelly O, Cunningham C, Grogan L, Cronin H, O'Shea C, Roche M, et al. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. Dec 2020;144:104281. [FREE Full text] [CrossRef] [Medline]20], but also provide a modernized roadmap for undertaking the implementation process.
Seven Process-Based Recommendations for EHR Implementation
The literature consistently demonstrates the value of both the government and vendors in ensuring sustained EHR compliance processes, while highlighting some dangers. We drew from this some recommendations for successful compliance processes. The first recommendation is to maintain close and ongoing government/implementor relationships to balance user, government, and organizational requirements in the short and longer terms. There is a need for the central government to work with hospitals and local governments to ensure EHRs satisfy the requirements of users [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49]. Government planners have the power to exert more influence on public health care providers than private providers [Klecun E, Zhou Y, Kankanhalli A, Wee YH, Hibberd R. The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: a tale of two countries. J Inf Technol. Mar 27, 2019;34(4):292-332. [CrossRef]51]. Liaising with organizations and policy makers to inform strategic decisions and policy making is important [Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35]. As part of this, it is necessary for evaluators of EHRs to form close relationships with policy makers [Cresswell K. Evaluation of implementation of health IT. Stud Health Technol Inform. 2016;222:206-219. [Medline]35]. The second recommendation is to rebalance vendor/implementor relationships to ensure small-site customization and training that will drive sustained compliance. The role of the vendor is notable, with numerous best-practice sites viewing their vendor as an active partner in the implementation and compliance process [McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76]. Designating key contact people to act as liaisons may help foster this relationship from the beginning. Fostering open, regular communication between vendors and implementers can also be done through regular meetings.
The literature clearly highlights the importance of collaboration processes across teams, as well as multistakeholder communication, in ensuring sustained support for EHR implementation. Breakdown of communication and relationships is damaging to implementation processes. We built on these findings to suggest some collaboration processes that support EHR implementation. Our third recommendation, therefore, is to cultivate varied sources of support across stakeholder groups. Strong and continued commitment and support at the highest level facilitate and support collaboration processes [Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36]. The types of support needed vary to include political support [Cucciniello M, Guerrazzi C, Nasi G, Ongaro E. Coordination mechanisms for implementing complex innovations in the health care sector. Public Manag Rev. May 13, 2015;17(7):1040-1060. [CrossRef]36], practitioner support [Palvia P, Jacks T, Brown W. Critical issues in EHR implementation: provider and vendor perspectives. Commun Assoc Inf Syst. 2015:36. [FREE Full text] [CrossRef]108], and social support [Stanczyk NE, Crutzen R, Sewuster N, Schotanus E, Mulders M, Cremers HP. Differences in Sociocognitive Beliefs between Involved and Noninvolved Employees during the Implementation of an Electronic Health Record System. Perspect Health Inf Manag. 2017;14(Spring):1c. [FREE Full text] [Medline]109]. Supporting the interest in EHRs is an important behavior linked to successful EHR implementation [Boswell RA. A physician group's movement toward electronic health records: a case study using the transtheoretical model for organizational change. Consult Psychol J: Pract Res. Jun 2011;63(2):138-148. [CrossRef]95]. Indeed, issues may arise where there is inadequate patient and broader community engagement around EHR implementation [Pearce C, Bartlett J, Mcleod A, Eustace P, Amos R, Shearer M. Effectiveness of local support for the adoption of a national programme--a descriptive study. Inform Prim Care. 2014;21(4):171-178. [FREE Full text] [CrossRef] [Medline]88]. The fourth recommendation is to pay particular attention to communication and collaboration in the implementation-planning phase of EHR implementation, including the development of cross-functional teams, the appointment of “opinion leaders’” and realistic envisioning of postimplementation challenges and benefits. Effective communication processes are critical in an organization when implementing an EHR [Collins S, Alexander D, Moss J. Nursing domain of CI governance: recommendations for health IT adoption and optimization. J Am Med Inform Assoc. May 2015;22(3):697-706. [CrossRef] [Medline]70], especially during the implementation-planning phase [McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76]. Stakeholders working toward change also need a close collaborative working environment [van Offenbeek MA, Vos JF, Boonstra A. Understanding variation in subunit adoption of electronic health records: facilitating and constraining configurations of critical dependencies. Eur J Inf Syst. Jun 25, 2023;33(2):221-243. [CrossRef]65]. Forming cross-functional teams [Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60] and enlisting the collaborative effort of physicians, hospital administrators, IT specialists, and state officials are integral to the process of design and development [Hernández-Ávila JE, Palacio-Mejía LS, Lara-Esqueda A, Silvestre E, Agudelo-Botero M, Diana ML, et al. Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico. J Am Med Inform Assoc. 2013;20(2):238-244. [FREE Full text] [CrossRef] [Medline]48]. Appointing “opinion leaders” to hear concerns of practitioners makes audiences more receptive to implementation [Greenhalgh T, Stramer K, Bratan T, Byrne E, Mohammad Y, Russell J. Introduction of shared electronic records: multi-site case study using diffusion of innovation theory. BMJ. Oct 23, 2008;337:a1786. [FREE Full text] [CrossRef] [Medline]45]. Crafting communication campaigns that balance potential expected benefits with realistic expectations of the challenges faced may be an issue [Crowley K, Mishra A, Cruz-Cano R, Gold R, Kleinman D, Agarwal R. Electronic health record implementation findings at a large, suburban health and human services department. J Public Health Manag Pract. 2019;25(1):E11-E16. [FREE Full text] [CrossRef] [Medline]59]. Anticipating the challenges that will be faced during implementation can cause these issues, as each implementation occurs in a unique environment.
The studies clearly show the importance of competence-building processes, such as training and technical support provision during the implementation process. We drew from this to suggest competence-building processes that will positively contribute to the EHR implementation process. The fifth recommendation is to ensure that staff are adequately trained to use the systems and for planners to consider the timing of this training when organizing wider implementation processes. Implementation processes depend on training the staff who will be using the system [Noblin A, Cortelyou-Ward K, Cantiello J, Breyer T, Oliveira L, Dangiolo M, et al. EHR implementation in a new clinic: a case study of clinician perceptions. J Med Syst. Aug 2013;37(4):9955. [CrossRef] [Medline]77]. Ongoing training and optimization are necessary [Sheehan OM, Greene RA, McKernan J, Murphy B, Cahill C, Cleary B, et al. Introduction of a single electronic health record for maternity units in Ireland: outline of the experiences of the project management team. JMIR Form Res. May 12, 2023;7:e38938. [CrossRef]103], as well as curricula for EHR training [Shield RR, Goldman RE, Anthony DA, Wang N, Doyle RJ, Borkan J. Gradual electronic health record implementation: new insights on physician and patient adaptation. Ann Fam Med. Jul 19, 2010;8(4):316-326. [FREE Full text] [CrossRef] [Medline]104]. Training processes must be ongoing, embedded in workflows, and flexible so that they can be tailored to the diverse needs of users [Takian A, Sheikh A, Barber N. Organizational learning in the implementation and adoption of national electronic health records: case studies of two hospitals participating in the National Programme for Information Technology in England. Health Inform J. Oct 02, 2014;20(3):199-212. [FREE Full text] [CrossRef] [Medline]89]. In terms of timing, training should be conducted close to the time of actual implementation of new technology [Vadillo PC, Rojo ES, Garces A, Checton MG. Maximizing healthcare professionals' use of new computer technologies in a small, urban hospital's critical care unit. J Healthc Manag. 2016;61(5):352-362. [CrossRef]54], with the most successful training session conducted within a few weeks of the system going live [McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76]. Some authors recommend that staff be required to complete training by the end of the preparatory phase to retain their access to the EHR [Banas CA, Erskine AR, Sun S, Retchin SM. Phased implementation of electronic health records through an office of clinical transformation. J Am Med Inform Assoc. Sep 01, 2011;18(5):721-725. [FREE Full text] [CrossRef] [Medline]94]. Others suggest sending staff to training classes customized by job role, with trainers on-site for 1-2 weeks after the system goes live [Strong D, Volkoff O, Johnson S, Pelletier L, Tulu B, Bar-On I, et al. A theory of organization-EHR affordance actualization. JAIS. Feb 2014;15(2):53-85. [CrossRef]64]. The time it takes practitioners to chart should be addressed early on in training [Tobler N, Colvin J, Rawlins NW. Longitudinal analysis and coping model of user adaptation. J Comp Inf Syst. Jul 22, 2016;57(2):97-105. [CrossRef]53], and training focusing on how the EHR will work should be replaced with a focus on how the EHR can be adapted to the practitioners [Tobler N, Colvin J, Rawlins NW. Longitudinal analysis and coping model of user adaptation. J Comp Inf Syst. Jul 22, 2016;57(2):97-105. [CrossRef]53]. Vadillo et al [Vadillo PC, Rojo ES, Garces A, Checton MG. Maximizing healthcare professionals' use of new computer technologies in a small, urban hospital's critical care unit. J Healthc Manag. 2016;61(5):352-362. [CrossRef]54] stress the importance of providing proper training in basic computer functions, with training conducted in the classroom with an instructor rather than one to one. Recommendations also suggest that senior management provide practice leaders with IT training and have them visit an EHR-based practice [Zandieh SO, Yoon-Flannery K, Kuperman GJ, Langsam DJ, Hyman D, Kaushal R. Challenges to EHR implementation in electronic- versus paper-based office practices. J Gen Intern Med. Jul 28, 2008;23(6):755-761. [FREE Full text] [CrossRef] [Medline]97]. The sixth recommendation is to assess what support will be needed at each stage of the implementation and ensure that this support is put in place for an appropriate amount of time. Support is critical during the go-live period [McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76]. Carayon et al [Carayon P, Smith P, Hundt AS, Kuruchittham V, Li Q. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behav Inf Technol. Jan 2009;28(1):5-20. [CrossRef]69] suggest having support staff present from the EHR vendor on the day the EHR goes live and having an expert user present at the clinic for the following weeks as a useful support to implementation processes. The availability of “super users” who offer support at go-live time is also noted as appropriate [Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60] and particularly useful when considering user support as a higher priority than initial user training [deRiel E, Puttkammer N, Hyppolite N, Diallo J, Wagner S, Honoré JG, et al. Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti. Health Policy Plan. Mar 01, 2018;33(2):237-246. [CrossRef] [Medline]39]. Other notable forms of support are vendor support [Deokar AV, Sarnikar S. Understanding process change management in electronic health record implementations. Inf Syst e-Bus Manag. Jul 1, 2014;14(4):733-766. [CrossRef]60] and industry support [Fragidis LL, Chatzoglou PD. Implementation of a nationwide electronic health record (EHR). IJHCQA. Mar 12, 2018;31(2):116-130. [CrossRef]42]. Informal support (provided via Facebook, involving both vendors and peer-to-peer support) is also noted to be effective and efficient [Hertzum M, Ellingsen G, Melby L. Drivers of expectations: why are Norwegian general practitioners skeptical of a prospective electronic health record? Health Inform J. Jan 13, 2021;27(1):1460458220987298. [FREE Full text] [CrossRef] [Medline]74]. Support throughout the planning and implementation period ensures clarity of roles, strong communication practices, and a successful outcome [Kiepek W, Sengstack PP. An evaluation of system end-user support during implementation of an electronic health record using the model for improvement framework. Appl Clin Inform. Oct 18, 2019;10(5):964-971. [FREE Full text] [CrossRef] [Medline]84].
Finally, the literature clearly demonstrates the integral role of cost throughout implementation. We drew from this discussion of cost in the literature to provide our concluding recommendation. The seventh recommendation is to promote an understanding of the system as a long-term investment. Some of the literature promotes the development process of a solid government reimbursement plan [Jung SY, Lee K, Lee H, Hwang H. Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: a qualitative analysis. Int J Med Inform. Dec 2020;143:104244. [FREE Full text] [CrossRef] [Medline]49]. However, more central to our recommendation is deRiel et al’s study [deRiel E, Puttkammer N, Hyppolite N, Diallo J, Wagner S, Honoré JG, et al. Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti. Health Policy Plan. Mar 01, 2018;33(2):237-246. [CrossRef] [Medline]39]. The authors discuss the importance of understanding the system, its value, and the total cost of ownership so that investments are not seen as one-time expenses but ongoing investments. Other authors suggest that the process of choosing an EHR system should center on its potential for improving clinical care rather than achieving cost savings [Takian A, Sheikh A, Barber N. We are bitter, but we are better off: case study of the implementation of an electronic health record system into a mental health hospital in England. BMC Health Serv Res. Dec 31, 2012;12(1):484. [FREE Full text] [CrossRef] [Medline]96]. Inadequate practitioner consultation processes [Greenhalgh T, Hinder S, Stramer K, Bratan T, Russell J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ. Dec 16, 2010;341:c5814. [FREE Full text] [CrossRef] [Medline]46], delays [Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation. BMJ. Oct 01, 2010;341(sep01 3):c4564-c4564. [FREE Full text] [CrossRef] [Medline]58], and tendering processes all increase the cost of the overall process [Boonstra A, van Offenbeek MAG, Vos JFJ. Tension awareness of stakeholders in large technology projects: a duality perspective. Project Manag J. Feb 01, 2017;48(1):19-36. [CrossRef]34].
Our findings illustrate that successful implementation processes benefit from meticulous planning [McAlearney AS, Sieck C, Hefner J, Robbins J, Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. Biomed Res Int. 2013;2013:629574-629579. [FREE Full text] [CrossRef] [Medline]76]. Our recommended processes for addressing compliance, collaboration, competence, and costs within the wider EHR implementation process aim to provide the materials for informed “meticulous process planning” to occur. Examining EHR implementation purely from a pre- versus postimplementation perspective of outcomes may blind both researchers and practitioners to the importance of the intervening implementation processes. Our review connects previously established barriers and facilitators with a time-and-action focus to offer additional insights into the process of implementation.
Limitations
Several limitations should be considered in this scoping review. This study focused on EHRs and did not consider the implementation processes of other eHealth systems, which may benefit from future analysis. Our findings also highlight the need for improved standardization in the terminology surrounding electronic records in health care to better differentiate between EHRs and EMRs in both research and practice. This improved clarity would allow for greater comparability across studies and guide more tailored implementation processes. The included studies tended toward the United States and Europe, centering our analysis in the Global North. The search strategy included studies from 1999 onward. The resulting studies selected were mostly from 2007 onward. It is unlikely that this date limitation largely impacted the selected studies; however. it is possible that due to the date limitation, this scoping review may have missed interesting studies conducted prior to 1999. Finally, our specific search terms, chosen with the intention of focusing the literature on the implementation process, may mean that the literature describing the same event but not using those specific search terms was not retrieved. Additionally, shifts in the language and naming of systems in health care mean that this study may apply to systems discussed under a name other than “EHRs,” which have not been retrieved during the search strategy of this research. As such, we did not retrieve or include any studies discussing EHRs under the recently emerging term of “digital health records.”
Conclusion
Completed implementation of EHRs is integral to improving health care delivery. The findings from this scoping review offer important insights into the complexities of the actual process of implementation and its subprocesses. Our review identified 3 key processes (compliance, collaboration, and competence building), as well as considering overall process costs. In doing so, we offered a new time- and action-based perspective on EHR implementation. Compliance processes reference the role of the government, policy, regulation, and vendors in shaping the implementation process. Collaboration processes promote the need for strong communication and the building of relationships across all stakeholders involved in the implementation process. Competence-building processes focus on ensuring that users are provided with the resources to be able to operate an EHR, centering around the importance of the timing of training and support. Finally, our discussion of process cost illustrates the importance of a time-focused financial approach during the implementation process.
We proposed 7 strategies in this review, which all provide a structured approach to navigating the different areas of implementation. Future research should focus on deepening our understanding of how these outlined strategies change and operate at different stages of the implementation process. This scoping review contributes to the intersection of management and health care research. We hope that the review results and recommended strategies provided will inform areas for future research and help develop future implementation processes.
Acknowledgments
This publication emanated from research conducted with the financial support of Taighde Éireann–Research Ireland (grant GOIPG/2021/290).
Data Availability
All data analyzed during this study are included in this paper.
Authors' Contributions
HF was responsible for conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, visualization, and writing—original draft. NM managed supervision, validation, and writing—review and editing.
Conflicts of Interest
None declared.
Multimedia Appendix 1
PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.
DOCX File , 68 KBReferences
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Abbreviations
EHR: electronic health record |
EMR: electronic medical record |
PHR: personal health record |
PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews |
Edited by G Eysenbach; submitted 30.04.24; peer-reviewed by S Lloyd, F Lau; comments to author 19.07.24; revised version received 18.10.24; accepted 07.12.24; published 03.03.25.
Copyright©Harriet Finnegan, Nicola Mountford. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 03.03.2025.
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