Challenges of EHR Implementation and Related Guidelines in Isfahan

Abstract

Introduction: Today, eHealth is base of health services around the world, and electronic health records as an essential core element and its basic architecture for telehealth is considered. EHR offers many potential opportunities for healthcare systems we must focus on its challenges and related guidelines but for EHR deployment. The purpose of this paper is exploration challenges of EHR implementation and related guidelines in Isfahan. Methods: This is a qualitative study and we used the method of phenomenology, a in-depth semi-structured interviews were conducted with 15 of Physicians, Managers and Clear Sighted persons who had experiences regarding with electronic health record. Conclusion: The researcher divided challenges into two areas of infrastructure and structural. Challenges of electronic health records infrastructure are due to information technology, lack of uniform definitions and concepts, cultural problems, and lack of needs assessment before implementation and the challenges of structural are due to instability enforced, violations of privacy and legal cases, compromise getting information management, and lack of integration and sharing of enterprise-level.

Full text

Procedia Computer Science 00 (2010) 000–000
Procedia
Computer
Science
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Challenges of EHR Implementation and Related Guidelines in Isfahan
Maryam Jahanbakhsha, Nahid Tavakoli b,Dr Habibollah Mokhtar ic
a

a,b Isfahan University of Medical Sciences,Hezar Jarib Street,Isfahan,8176845513,Iran
c. Oil Industry’s Polyclinic,Artesh Square,Isfahan,8174754749,Iran
Abstract
Introduction: Today, eHe alth is base of healt h services ar ound the world, and electronic health records as an essential core
element and its basic architecture for telehealth is considered. EHR offers many potential opportunities for healthcare systems we
must focus on its challenges and related guidelines but for EHR deployment. The purpose of this paper is exploration challenges
of EHR implementation and related guidelines in Isfahan. Methods: This is a qualitative study and we used the method of
phenomenology, a in-depth semi-structured interviews were conducted with 15 of Physicians, Managers and Clear Sighted
persons who had experiences regarding with electronic health record. Conclusion: The researcher divided challenges into two
areas of infrastructure and structural. Challenges of electronic health records infrastructure are due to information technology,
lack of uniform definitions and concepts, cultural problems, and lack of needs assessment before implementation and the
challenges of structural are due to instability enforced, violations of privacy and legal cases, compromise getting information
management, and lack of integration and sharing of enterprise-level.
Keywords: Challenges; Electronic Health Record; Isfahan
1. Introd uction
Today, eHealth is base of h ealth services around the world, and electronic health r ecords as an essential core
element [1] and its basic architecture for telehealth is considered[2].
The concept of computerization of medical records was introduced about 30 years ago under different names, such
as electronic medical records, computerized medical records, electronic records and other names. Vision of
electronic health r ecords ar e not fixed in different communities as well as its opportunities and challenges to be
considered. Electr onic health r ecord briefly support the possibility of integration of patient data, clinical decision
support, online data entry by clinicians, access to knowledge resources and multiple information needs of users
while designing interface engines, develop the necessa ry standards, legal and social issues, costs, and leadership and
management, including the challenges ahead in its application that must be considered[3].
Some institutions/countries are currently planning the introduction of a nationwide electronic health record while
others have
actually implemented some form of EHR. However, the type and extent of electronic health records vary an d what
one country calls an EHR ma y not be the same as that developed in another country. Alth ough work has been
undertaken by institutions/countries on some form of a computerized patient healthcare information system, as yet
 Maryam Jahanbakhsh. Tel : +98-311-7922029 ; fax : +98-31- 6684799
Email address : jahanbakhsh.him@gmail.com
Procedia Computer Science 3 (2011) 1199–1204
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1877-0509 c
⃝2010 Published by Elsevier Ltd.
doi:10.1016/j.procs.2010.12.194
c
⃝2010 Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
Selection and/or peer-review under responsibility of the Guest Editor.
Open access under CC BY-NC-ND license.

Maryam Jahanbakhsh / Procedia Computer Science 00 (2010) 000–000
not many hospitals have successfully introduced an electronic health record with clinical data entry at the point of
care[3].
In addition to the above, resistance by some medical practitioners and health professionals generally to a change
from manual to electronic documentation may be a problem in both developed and developing countries. Most
health administrators and information managers are aware that it may take time to change or at least modify health
practitioner behavior and attitudes. The reason for wanting to change to an electronic system is important.The vision
of the EHR is not fixed. This is both its challenge and its strength in different communities[1]. Therefore, the
researcher tried to investigate the challenges resulting from the introduction and implementation of electronic health
records and related guidlines from the perspective of cust odians and clear-sighted persons.
2. Methods
The current study is done using a qualitative method in Isfahan in 2010. In this study the method of phenomenology
was used. Thus, in-depth semi-structured interviews were conducted with 15 of Physicians, Managers and Clear
Sighted persons who had experiences regarding with electronic health record. Snowball Samplin g is the method
used in this resear ch work to obtain their knowledge. First of all a content analysis was done on the gathered data,
and then based on the purpose of the research which contained opportunities of EHR, they were described &
presented trough using the subject coding.
3. Results
Based on the comments made by in terviewees the researcher divided Challenges into t wo subcategories of
Infrastructure and Structure .
The following table shows the findings of EHR Challenges and its subcategories:
Table 1: Challenges of introduction and implementation of EHR
Challenges
Interviewees
Infrastructure Structure
Physicians Lack of users’ training
Weakness of relationship between doctors and patients
Limitation of digital signature
No suita ble forma t for data e ntry
Non-effective services for data retrieval and edit
Mana gers Costs of EHR system s
Lack of common language between designers and users
No acceptance of EHR by many users
No expert staff for supporti ng and mai ntenance of the
system
Lack of financial su pporting for implementation of EHR
Legal restricti ons of EHR
No readiness for data interchange among organizations
Clear-sighted
persons
Costs of software and hardware
Costs of buying EDI standards
Restriction for using the Oracle
Low speed of existence information and communication
switches
Lack of management of entered data
No possib ility for exter nal user s of EHR
No attenti on to integrati on data from bir th to dea th
Generally infrastr ucture challenges have been divided into four categories :
1. IT-related problems includes:
- cost of hardware
- Cost of software
-Poor communication standards and requirements
- Applied system software weaknesses
Proposed guidelines to face the challenges associated with information technology from the perspective of
interviewees include:
a. Switch designed for high-volume data transmission such as video data
b. Databases for normalizing data
c. Using SQL server 2008
d. Replace the waterfall model with a cycle model
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Maryam Jahanbakhsh / Procedia Computer Science 00 (2010) 000–000
e. Use the time limit online access to records
f. Correct defects existing HIS
g. Determine the exact procedures to work on basic layers such as data warehousing or data mining
2. Lack of uniform definitions and concepts and no common language between designers, users and custodians
Proposed guidelines to face the challenges resultin g from lack of uniform definitions and concepts of electronic
health records from the views of interviewees include:
a. Involving trade unions about such insurance, radiology, and etc.
b. Defined localization of EHR
c. Standardization of data in order to harvest all the same
d. V & V (Verification and Validity) of Information
3. Cultural problems includes:
- Rejection by some users
-Weakness of relationship between physician and patient
Proposed guidelines to face the challenges related to cultural pr oblems from the perspective of managers are:
a. Describe EHR benefits to public
b. Advertise through the media about EHR
c. Motivate organizations to adopt EHR
d. Identify users’ perceptions about EHR
e. Improving EHR through training
4. Lack of needs assessment
due to
:
- Unsuitable platform for implementing electronic health records
- gap between administrative and clinical needs
Proposed guidelines to face the challenges resultin g from the lack of needs assessment from the perspective of
interviewees include:
a. Identify and define information needs of patients, healthcare providers and other customers
b. Exploratory studies in order to implement EHR
c. Meetings with managers of organizations before implementing EHR
Also structural challenges that the researcher has divided into three sections:
1. Instability enforcement due to:
- lack of transparency, responsibility, preserve and promote electronic health records
- competent organs of poor funding
Proposed guidelines to face the challenges resulting from the lack of consistency in enforcement from the
perspective of interviewees include:
a. Create subspecialty committees as subcommittee of EHR Strategic Committee
b. Funding by the private sectors
c. Create a ministry or organization as a national trust with interactive EHR and related ministries
d. Governmental support to run the EHR
e. Participation of the Ministry of Health as the main custodian and telecommunications centre as a supporting
organization
2. Legal and privacy violations due to:
- possible compromise to privacy and confidentiality
- lack of acceptance in the judicial and legal cases
Proposed guidelines to face the challenges related to data privacy violations from the perspective of interviewees
include:
a. Create master card for users
b. Create special password for patients
c. Determine access levels for authorized users
3. Lack of integration and sharing of enterprise-level such as:
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- restrictions on the use of patient information in outside of hospital
- lack of integrity and non electronic health records projects in the province
Proposed guidelines to face the challenges associated with lack of integration and sharin g across organizational
learn the views of managers is:
Networkin g and linking health care organizations in the province
4. Conclusion
According to the point of views of interviews , the challenges of the implementation of EHR can be divided into two
categories : Infrastructure an d structure such as :information technology problems , lack of need assessment ,
cultural problems , high software and hardware cost and non-adjustment data interchange standards . Other studies
in this area are as follows:
Seven key findings emerged: users perceived the decision to adopt the electronic medical record system as flawed;
software design problems increased resistance; the system reduced doctors' productivity, especially during initial
implementation, which fuelled resistance; the system required clarification of clinical roles and responsibilities,
which was traumatic for some individuals; a cooperative culture created trade-offs at varying points in the
implementation; no single leadership style was optimal—a participatory, consensus-building style may lead to more
effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during
implementation; the process fostered a counter climate of conflict, which was resolved by withdrawal of the initial
system[4].
EMRs are very difficult to construct because the existing electronic data sources, e.g., laboratory systems, pharmacy
systems, and physician dictation systems, reside on many isolated islands with differing structures, differing levels
of granularity, and differ ent code systems. To accelerate EMR deployment we need t o focus on th e interfaces
instead of the EMR system. We have the interface solutions in the form of standards: IP, HL7 / ASTM, DICOM,
LOINC, SNOMED, and others developed by the medical informatics community. We just have to embrace them.
One remaining problem is the efficient capture of physician information in a coded form. Research is still needed to
solve this last problem.
The standards needed to tran sport patient data from one system to another inexpensively are in place. With these
standards we can solve man y of the problems and create a first-stage medical record system from the extensive
medical data that already exist in systems such as laboratory, pharmacy, dictation, scheduling, EKG cart, and case
abstract systems.
Standard mechanisms for commun icating over networks in a secur e fashion exi st, as do stan dards for delivering
structured medical record content like patient registry records, orders, test results, and standard identifiers for coding
many (but not yet all) of the concepts we want to report in the fields of such structured records.
The message standards do n ot specify the ch oice of codes for many fields. They do provide a mechanism for
identifying the code s ystem for every transmitted code. This pleuralistic strategy was the only alternative in the past
because universal code systems did not exist for important topics such as laboratory tests and clinical measurements;
so institutions used their own local codes. Fortunately, universal code systems are now available for subject matter
such as units of measure (ISO+21), laboratory observations (LOINC22), common clinical measurements (LOINC), drug
entities (NDC23), device classifications (UMDNS24), organism names, topolog y, sympt oms and pathology
(SNOMED,25 IUPAC26 ), and outcomes variables (HOI27). Even better, most are available without cost. So, for at least
some source systems, we have all of th e pieces needed for creating EMRs inexpensively from multiple independent
sources, inside and outside of a h ealth car e organization[5].
One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased
the quality of the patient–doctor interaction [6].
Infor mation technology offers many pot ential advantages over paper for the storage an d retrieva l of patients' data.
Enthusiasts predict that soon all records will be stored and viewed on computer, but others are more sceptical. The
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failure of some computer-based records may be due to poor information design. This paper explores how computers
broaden the range of design options but points out that more attention to design is required for computer-based than
for paper-based records[7].
The Challenges of electronic health records infrastructure related to information technology, lack of uniform
definitions and concepts, cultural pr oblems, and lack needs assessment before implementation and the challenges of
structural instability enforced, violations of privacy and legal cases, compromise getting information management,
and lack of integration and sharing of enterprise-level call to separation.
Overall study results indicate:
* Although electronic health records provides many opportunities for health systems but there are man y challenges
in the way that it has the adverse effects of quality of EHR implementation and should be put through the
implementation of strategies, including strategies presented in this study .
* According to th e resear ch , often hardware and soft ware en gineers have been more fully than others have touched
the practical challenges and offering solutions and therefore must have key role in Executive Committees of
electronic health records.
* Alth ough most users of electronic health records are physicians, but have presented minimal comments about
challenges and shortcomings and if res it resulted from
their weak roles in introducing and implementation of electronic health records will follow harmful results.
* Based on the present findin gs should pave the executable file, e-hea lth challenges by improving in formation
technolog y, electronic health records defined l ocalization, development and promotion of culture of electronic
health records, needs assessment and review requirements for implementing electronic health r ecords, warranties
established administrative and financial support of electronic health records vendors, supporting the principle of
confidentiality of information, improving information management through electronic health records, and facilitate
information integration of patients in different health systems.
* Electronic health records check in other leading countries in this area shows that implementation of this system
requires a strategic and an executive committee but this research study shows unfortunately necessary attention in
this regard has been taken.
Practical suggestions
- Strategic and executive committee prior to electronic health r ecords pr oject
- Customer needs assessment of electronic health records
- Solving the challenges of infrastructure prior to implementing electronic health records
Acknowledgements
The authors would like to thank the Isfahan University of Medical Sciences for supporting to do this study and the
managers and physicians who participated in this research project as interviewees .
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