Implementation of an electronic health record

Involves numerous challenges, but examples show it can be done successfully

Implementing an electronic health record along with computerised
provider order entry and clinical decision support is hard.

Integrating these advanced technologies into a complex and rapidly
changing healthcare delivery environment is a major task, but the
associated cultural, process, and change management obstacles make the
task even harder. Furthermore, the challenges and costs often accrue
long before any real value of the effort is seen.

The current controversy regarding the NHS effort to implement a
system-wide electronic health record is a good case study of how
difficult these initiatives can be.1 When health systems encounter the
associated and inevitable difficulties, the natural inclination is to
question whether the aggravation and effort is worthwhile. This is
clearly at the core of the debate in the United Kingdom regarding the
NHS effort. At such times, leaders who are seriously interested in
improving the safety, quality, efficacy, and cost of care need to do
what all good leaders do—pause, carefully assess the situation, and
learn from the experience of their efforts as well as that of others.
They should then use this knowledge to determine how to achieve the
ultimate goals of the initiative—better and more efficient care for

The implementation of an electronic health record that produces value
for patients and purchasers is a continuous learning opportunity. This
is shown by Sheikh and colleagues in a linked longitudinal qualitative
evaluation (doi:10.1136/bmj.d6054), which assesses the implementation
and adoption of the NHS Care Records Service in 12 English “early
adopter” hospitals.2 Overall, the authors concluded that
implementation of the NHS service was time consuming and challenging,
with limited distinct benefits for clinicians and no clear advantages
for patients. Although the study highlights the difficulties of these
endeavours, it should not dissuade clinicians or policy makers from
striving for the ultimate goal—to provide healthcare value defined by
higher quality, increased safety, and greater access to good care at a
reasonable cost.

This goal is not possible without using a combination of advanced
information technology and knowledge management to capture, code, and
disseminate health information in the form of electronic health
records. Such records have enormous potential to improve the flow of
information across healthcare settings and systems. Furthermore,
computerised provider order entry coupled with advanced clinical
decision support can improve the safety, quality, and cost of care.3
The implementation of electronic health records is not about
digitising the paper chart, but about laying the foundation for
achieving better outcomes through better access to information and
better decisions.

What are the key practical lessons for those who are trying to
implement such systems? A summary report by the National Alliance for
Health Information Technology provides some useful categories of
crucial success factors.4

The goal is to improve care, not information technology. IT is a
powerful enabler, nothing more. Crucial success factors are: careful
definition of project goals in terms of better care for patients,
development of metrics to measure progress in achieving these goals,
creation of change management and comprehensive communication plans,
and the refinement of organisational policies and procedures to
reflect the changes produced by the implementation.

Manage culture and change. It is crucial to understand the culture of
an organisation. New systems inevitably introduce major changes to
traditional care processes and work flows, which often produces
substantial resistance from staff. A comprehensive change management
plan is crucial to overcoming cultural resistance and should provide
the education and motivation people need for change to happen.5

Engage clinicians. The views of those involved in the implementation
must be built into the implementation early and often. Clinical groups
led by respected clinical champions must be educated, informed,
inspired, and engaged. They should be involved in creating the project
goals and standard success metrics, participate in the development and
execution of the communication plan, validate clinical process and
workflow changes, and help to inform and influence their clinical
peers as to why the initiative is important to patient care.

Improve processes and workflow. Implementations are an opportunity to
examine current processes and workflow practices, eliminate
unnecessary workarounds, and improve the delivery of care. Without
proper analysis, inefficient practices can become simply entrenched
rather than improved. If existing process and workflow are adequate,
maintain them.

Test on the end user. End user testing should be done before
implementation and feedback should be incorporated.

Train and educate. Careful attention to methods of training and how it
is offered will pay dividends in terms of acceptance by the end user
and achievement of organisational goals. Too much training overwhelms
users with information and can become annoying, but too little will
mean goals are not achieved. Just in time training (training shortly
before implementation) often works best for busy clinicians. Such
training can include practice systems, online courses, and “at the
elbow” ad hoc support from other knowledgeable users.

Communicate. Communicate frequently about progress, challenges, and
mistakes.4 It is also equally important to listen and respond to
constructive feedback.

Incorporating advanced information technology into the complex care
delivery environment so that it improves care processes and work flows
while also not harming patients or alienating clinicians is difficult.
Years of experience show that electronic health records and clinical
decision support can be implemented to improve individual and
population health,6 7 8 9 but it is not easy. The literature is full
of examples of lessons learnt, mistakes made, and outright failures.10
11 12 It is therefore important to view the implementation as a
learning opportunity, and not simply as either a success or a failure.

John L Haughom, senior vice president, clinical quality and patient safety
PeaceHealth, Eugene, OR 97405, USA
BMJ 2011;343:d5887