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IJHCQA
31,2
Implementation of a nationwide
electronic health record (EHR)
The international experience in 13 countries
116
Leonidas L. Fragidis and Prodromos D. Chatzoglou
School of Engineering, Democritus University of Thrace, Xanthi, Greece
Received 13 September 2016
Revised 18 May 2017
Accepted 22 June 2017
Abstract
Purpose – The purpose of this paper is to identify the best practices applied during the implementation process
of a national electronic health record (EHR) system. Furthermore, the main goal is to explore the knowledge
gained by experts from leading countries in the field of nationwide EHR system implementation, focusing on
some of the main success factors and difficulties, or failures, of the various implementation approaches.
Design/methodology/approach – To gather the necessary information, an international survey has been
conducted with expert participants from 13 countries (Denmark, Austria, Sweden, Norway, the UK, Germany,
the Netherlands, Switzerland, Canada, the USA, Israel, New Zealand and South Korea), who had been playing
varying key roles during the implementation process. Taking into consideration that each system is unique,
with each own (different) characteristics and many stakeholders, the methodological approach followed was
not oriented to offer the basis for comparing the implementation process, but rather, to allow us better
understand some of the pros and cons of each option.
Findings – Taking into account the heterogeneity of each country’s financing mechanism and health system,
the predominant EHR system implementation option is the middle-out approach. The main reasons which are
responsible for adopting a specific implementation approach are usually political. Furthermore, it is revealed
that the most significant success factor of a nationwide EHR system implementation process is the
commitment and involvement of all stakeholders. On the other hand, the lack of support and the negative
reaction to any change from the medical, nursing and administrative community is considered as the most
critical failure factor.
Originality/value – A strong point of the current research is the inclusion of experts from several countries
(13) spanning in four continents, identifying some common barriers, success factors and best practices
stemming from the experience obtained from these countries, with a sense of unification. An issue that should
never be overlooked or underestimated is the alignment between the functionality of the new EHR system and
users’ requirements.
Keywords Critical success factors, Critical failure factors, EHR implementation, Implementation barriers,
IT implementation approach
Paper type Research paper
International Journal of Health
Care Quality Assurance
Vol. 31 No. 2, 2018
pp. 116-130
© Emerald Publishing Limited
0952-6862
DOI 10.1108/IJHCQA-09-2016-0136
1. Introduction
Although previous studies have shown that the implementation process is as important as
the system itself, the implementation of nationwide electronic health record (NEHR)
system has progressed much more slowly worldwide than it was initially anticipated
(Morrison et al., 2011). There are a number of reasons, such as the continuously changing
system characteristics and the politically driven contractual relationships among
healthcare providers, which seems to prevent the successful completion of electronic
health record (EHR) system’s development (Sheikh et al., 2011). The majority of
stakeholders are aware of the magnitude of the problems arising from the implementation
of such a system and they understand that it is unrealistic to hold high expectations
concerning the operational functions of these systems.
The scope of this research is to point out the best practices, in respect to organizational
and operational issues, adopted during the implementation process of the NEHR system
already in operation worldwide. The main goal is to explore the knowledge gained by
experts in the field of NEHR system implementation. The NEHR system is defined as a
Conflicts of interest: the authors declare that they have no conflicts of interest in the research.
national information system which ensures interoperability between EHR systems
obtained/developed from different vendors, either in the public or private sector, which
meets specific national interoperable standards (Morrison et al., 2011). It is clarified that this
research attempts to present some of the common characteristics/problems of the
implementation of the NEHR system in a unified way ( framework) in order for the readers
to be able to understand the global development as far as this issue is concerned.
Subsequently, a further discussion regarding some of these issues is carried out.
In the current research, an international survey was conducted and experts (stakeholders)
with significant roles, from 13 countries, have accepted to participate and share their
experience with the research community. Four participants where the project managers of the
NEHR system implementation, three where the directors of the corresponding national
organization (or of the appropriate department) for NEHR implementation, while three more
participants have had the role of the principal advisor of the respective organization in their
countries, which is in charge for eHealth national infrastructure, strategy, policy and
standards. Furthermore, two more participates where the chief officers (chief information
officer or chief technology officer (CTO)) concerning eHealth development strategies,
standards for interoperability, business and technical architecture guidelines. Moreover, one
participant was the chairman of a national independent not-for-profit organization, promoting
EHR systems. Finally, eight participants come from Europe (Denmark, Austria, Sweden,
Norway, the UK, Germany, the Netherlands and Switzerland) and five from the rest of the
world (Canada, the USA, Israel, New Zealand and South Korea).
It should be made clear that the purpose of the survey was neither to compare the NEHR
implementation adopted from different countries, nor to develop a guide to successful
NEHR implementation. This is because the priorities that each country poses for EHR
implementation differ, something that naturally leads to the development and
implementation of a very diverse EHR system in each country. The current research
highlights the best practices and the different approaches adopted by the leading in the field
of NEHR implementation countries, taking into account the specific characteristics of each
country. This research, therefore, attempts to identify some of the critical success and failure
factors (difficulties – barriers) along with the best practices of the implementation process of
NEHR that could be used as a reference point for other countries that intend to follow.
2. Literature review
In Europe, 19 out of 33 countries are still at the planning stage of the development and
implementation process of a patient summary and EHR-like system (Stroetmann et al.,
2011). The leading in the field countries in Europe are Denmark, Sweden, Norway, Finland,
the UK, Austria, Germany, the Netherlands and Switzerland. Worldwide, Canada and
Australia are the countries with the most advanced stage of NEHR implementation
(Thomson et al., 2013).
Denmark is considered as a leading country as far as eHealth integration and healthcare
delivery services are concerned (Kierkegaard, 2013). Similarly, in Sweden, efforts toward
investigating relevant systems, both at the county and national level, are in progress aimed
at enhancing their compatibility in order to increase security and effectiveness ( Jerlvall and
Pehrsson, 2012). Furthermore, in Norway, a governmental organization, called the National
Health Network, is in charge for the establishment of a single information exchange
platform for health providers and authorities.
In England, the current approach introduces the Summary Care Records, which will
store a limited range of data (current medication, adverse reactions and allergies) for all
patients except those who choose not to have one (Cresswell et al., 2012). In Austria, EHR
was initiated in 2005 with the health reformation law (Austrian Health Care Reform Act,
2005). Like in other countries, the development of an EHR system in Austria is facing
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significant challenges, like standards definition and structure of the content, along with
terminology harmonization. The overall progress of the EHR project in Germany
(E-Health Act, 2015) has been delayed several times, due to the technical complexity and
strong resistance of health professional organizations (Hoerbsta et al., 2010).
Furthermore, in the Netherlands, the idea for an EHR system was initially discussed in
October 1996 (Barjis, 2010). Dutch authorities have already establish, a central health
information technology (HIT) network, called AORTA, in order to facilitate information
exchange across healthcare providers. Moreover, Switzerland’s health system is recognized
as a high quality and high cost one (OECD/WHO, 2011). However, the interoperability of all
EHR systems has not been achieved yet, since the integration of hospitals’ EHRs varies
significantly among cantons.
In Canada, there is not a national strategy for implementing an NEHR system and there
is no national patient identifier (Mossialos et al., 2016). However, efforts for the adoption of
interoperable EHR are increasing rapidly and, according to Infoway’s Corporate Plan
2016-2017, efforts for establishing pan-Canadian common standards and interoperability
will be continued.
On the other hand, the USA decided in 2003 that its residents should have an EHR
system in ten years, adopting the bottom-up implementation approach. Later, on February
2009, the American Recovery and Reinvestment Act (2009) was introduced, where the
Health Information Technology for Economic and Clinical Health Act was enacted, in order
to promote and expand the adoption of HIT.
In Australia, a new commission for eHealth is in charge from July 2016, and the person
controlled EHR system was online in July 2012. Furthermore, in September 2010,
New Zealand launched the National Health IT Plan. The main challenge is the difficulty of
the implementation of a national patient portal taking into account the current low level of
interoperability among EHR systems and, also, considering that there are legacy systems
which are still operable (Monsen et al., 2010).
Israel is the first country in the world that introduced (in mid 1990s) health IT
information exchange systems, with virtually 100 percent of its primary-care doctors
using EHR (Peterburg, 2010). There is not a central point where the data are kept but all
information remains in its original format, location, system and ownership. Finally in
Korea, a health information exchange project was initiated by the government, in 2014,
with the aim of establishing a healthcare ICT infrastructure, which will be able to support
systems integration and share and utilize health information, using both wired and
wireless networking.
2.1 Similar studies
A very useful research concerning the adoption of electronic medical records in primary care
and the lessons learned from health information system (HIS) implementation experience in
seven countries (Canada, the USA, Denmark, Sweden, Australia, New Zealand and the UK)
was conducted by Ludwick and Doucette (2009). These researchers suggests that the
quality of the implementation process is as important as the quality of the system being
implemented. They also stresses that, in order EHR implementation process to be
successful, factors such as health system usability, computer skills and system’s fit within
the organizational culture should be carefully considered. Additionally, the same study has
shown that the outcome of the implementation process is affected by the quality of the
design of the systems graphical user interface, the functionality of the features incorporated,
project management, procurement and users’ previous experience.
Another relevant study concerning the problems of EHR systems in five countries
(England, Germany, Canada, Denmark and Australia) has been conducted by Deutsch et al.
(2010). They found that strategic, organizational and human challenges are usually more
difficult to master than technical aspects. The critical areas were used in the current
research in setting up a number of structured questions, concerning the main difficulties
faced during the implementation process (as illustrated in Table II).
Furthermore, Stroetmann et al. (2006) studied ten European eHealth projects, and
determined six key factors for the successful development and implementation of health
systems. These six key factors were also used in the current study in order to identify the
critical success factors as far as the implementation of an EHR system is concerned
(as presented in Table IV ).
Lluch (2011) reviewed the relevant literature in order to identify the barriers to the use of
HIT in the health sector. The main finding of this study is that some of the barriers
preventing a successful HIT implementation can be approached from an organizational
management perspective. Similarly, McGinn et al. (2011) conducted a systematic literature
review, aiming to provide a synthesis of the knowledge about the barriers and facilitators
influencing shared EHR implementation among its various users. It was revealed that the
most frequent adoption factors, common to all user groups, were: design and technical
concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity
and ability with EHR, motivation to use EHR, patient and health professional interaction
and lack of time and workload. The main conclusion was that, despite the fact that
important similarities exist between user groups, there are also significant differences, thus,
suggesting that each user group has a unique perspective on the implementation process
that should be taken into account.
Another study (Morrison et al., 2011), concerning the approaches used for an NEHR
system implementation, has shown how different healthcare systems, national policy
contexts and anticipated benefits have shaped the initial strategies. Coiera’s (2009)
typology of national programs (“top-down,” “bottom-up” and “middle-out”) was used in
order to review EHR system implementation strategies in three representative countries:
England, the USA and Australia. In England, a government-driven centralized national
approach was applied and this approach is considered as a “top-down” approach.
In contrast to the English approach, the USA decided to either transform local healthcare
organizations’ operational systems or develop new local healthcare information systems,
which represents the “bottom-up” approach. Australia, on the other hand, followed a
“middle-out” approach, where the government finances and supports national
infrastructure, standards development and tools (combined with local choice for
compatible, clinical IT systems). With middle-out approach, the local healthcare providers,
along with their IT vendors, progressively change their information systems with the aim
to comply with national information systems standards, in order to achieve higher
interoperability standards with the evolving national health information network.
Interoperable EHR systems are considered as an important tool with the potential to
control healthcare cost (Kaushal et al., 2015).
3. Research methodology
The primary aim of this research was to capture the existing experience from countries
where nationwide EHR systems have already been implemented or they are in a medium to
mature implementation phase. For that reason, experts with experience in implementing
NEHR in many different countries were invited to participate in this survey and share their
knowledge and experience with the academic community and other practitioners.
3.1 Survey design
Initially, the appropriate questions were identified from the available relevant scientific
literature and experts in the field of HIS implementation. More specifically, a number of
lengthy discussions took place with medical, nursing, technical and administrative staff.
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Particular attention was given to the interviews that were conducted with expert staff of the
IT departments of hospitals (developers, analysts and head of department), in order to
clarify the most appropriate questions.
Useful discussions and information exchange with researchers in the field of HIS,
eHealth and EHR took place, in three relevant international scientific conferences, more
specifically during the 11th IEEE International Conference on Computer and Information
Technology (Pafos, Cyprus), HEALTHINF 2013 (Barcelona) and the 10th International
Conference on Information Communication Technologies in Health (Samos, Greece).
During the last conference, an invitation was from the chairman of a national independent
not-for-profit organization supporting high-quality HER, to join the LinkedIn Professional
Network group of the European Federation for Medical Informatics – Health Information
Management in Europe (EFMI-HIME). After joining this specific group, we opened a
discussion in EFMI-HIME group titled “Technical and Operational information of EHR
System and Implementation difficulties (approaches).” The response of eight members who
are specializing in the field of eHealth participated in the discussion. From this opinion
exchange process, some very useful suggestions, concerning the structure of the survey and
the consideration of new sources concerning EHR implementation, were obtained. After a
careful consideration of the propositions expressed by the experts, it was decided to present
some of the initial findings concerning EHR implementation in a third conference in order to
receive new feedback ( from more researchers). A paper-based survey was conducted during
the 3rd HEALTHINF 2013 (International Conference on Health Informatics, Barcelona,
Spain) and the proposed international survey was validated and modified based on the
comments of more researchers in the field.
3.2 Survey instrument
Utilizing the experience gained from studying the literature and the discussions with
experts and researchers, a complete structured questionnaire was constructed. The
questionnaire consists of four sections (General questions, EHR implementation, Documents
submission and Additional info). Once the data collection instrument was completed, it was
evaluated by three e-HIS vendors before it was sent out to the appropriate participants
worldwide. A preliminary list of experts in the field of EHR systems implementation from
European organizations was generated and an evaluation request was sent to them.
The valuable feedback received, from a president of a European independent not-for-profit
organization promoting the use of high-quality EHR and from a treasurer of an association
concerning EHR standards helped us to modify the survey instrument in many sections
(more options were included in some structured questions) in order to improve the clarity of
the answers and, thus, their usefulness.
3.3 Participants identification
Initially, the website of the European Patient Smart Open Services (2014), which is a
European eHealth project that supports interoperability between EHR systems in Europe,
was used, since it offers a list of all project beneficiaries, including organization names and
contact details, of the representative person for each European country. An e-mail was sent
to all the representatives where a description of this research was included and a
participation in the survey request was addressed. In a few cases where no response was
received, a thorough search in each country’s organization website, which is responsible for
EHR implementation, was performed, in order for another person’s contact details to be
detected. The same method was followed for the non-European countries, in order for
specific contact details of the appropriate people to be obtained. These countries are:
Denmark (DK), Austria (AU), Sweden (SE), Norway (NO), the United Kingdom (UK),
Germany (DE), the Netherlands (NL), Switzerland (CH), Canada (CA), the United States of
America (USA), Israel (IL), New Zealand (NZ) and South Korea (KO). The participants of the
survey belong to different stakeholder group, such as ministries of health, national centers
of eHealth (coordinating and promoting nationwide use of IT), not-for-profit governmental
organizations (in charge for EHR implementation), Commonwealth Health Corporations and
independent not-for-profit organizations (EHR system certification development). There
were no excluding criteria for the participation of a country, but in contrast, an attempt was
made to find people from all the countries that have implemented (or are in the process of
implementing) NEHR systems.
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121
4. Results
In this section, part of the answers provided by each one of the 13 experts in each question is
presented. Since all the questions in the survey were optional, there are some boxes in some
tables which are blank indicating that no answer was provided. It should also be stressed
that, apart from choosing the answers for each question, the survey participants were also
asked to rate the importance of each given option, where it was applicable.
4.1 Healthcare systems
Three different types of healthcare systems exists worldwide (Fried and Gaydos, 2002).
These are the publicly funded systems (implying that a universal healthcare system exists
which is funded through taxation), the private-funded systems (personal contribution meets
the non-taxpayer refunded portion of healthcare) and the totally private systems (where
healthcare is either paid out of pocket or met by some form of personal- or employer-funded
insurance). Looking at the results (Table I), it can be easily noticed that in Europe
(all European countries except Switzerland – CH) the development and implementation of
EHR is totally publicly funded (except Germany – DE, where although 90 percent of the
statutory healthcare is publicly funded, there is also a small portion of 10 percent which is
totally private). On the other hand, from the non-European countries only Canada and
South Korea have publicly funded EHR Systems. Although in the USA, most people used to
pay for their insurance by themselves, with Medicare (national social insurance program),
National healthcare systems
Publicly funded
Private funded
Totally private
DK
UΚ
CA
|
|
|
EHR implementation approach – method used
Top-down
|
Bottom-up
Middle-out
|
#
|
US
IL
NZ
|
*
|
|
KO
CH
|
|
#
DE
SE
NO
AU
NL
*
|
|
|
|
|
|
|
|
|
|
|
|
|
#
|
Reasons of the chosen EHR implementation approach – method
Political reasons
(3)
(5)
(4)
(5)
(5)
(3) |
(4)
(5)
Current HIS
(4)
(4)
(5) |
|
(4)
Feasibility of implementation (5)
(4)
|
(4)
Cost
(3)
(3) (3)
Notes: Countries having adopted the middle-out, bottom-up and top-down approach. Tick symbol (|)
denotes participant’s selection. Blank space indicates that no answer was provided. Asterisk symbol (*)
indicates the initial approach used. Hash symbol (#) indicates future direction. Numbers indicate the level of
importance of each reason (1 ¼ slightly important, 2 ¼ fairly important, 3 ¼ important, 4 ¼ quite important,
5 ¼ very important)
Table I.
National healthcare
systems – EHR
implementation
approach
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122
health insurance is funded for citizens aged 65 and older, who have worked and paid into the
system through the payroll tax, while with Medicaid (social healthcare program), people
with low income, along with special cases (elderly, disabled, children, veterans), insurance is
covered by the government.
4.2 EHR implementation approach
Different EHR implementation approaches have been adopted from the participating
countries (Table I) in order for the EHR system to be operable. More specifically, three
countries have chosen the “top-down” approach, which is a government-driven centralized
national approach, four countries have chosen the “bottom-up” approach, where each local
healthcare organization transforms operational systems or develops new healthcare
information systems, while five countries have adopted the “middle-out” approach, where
the local healthcare providers progressively change their information systems in order to
comply with national information systems standards. It is worth mentioning that although
the top-down approach was used in the UK, it was abandoned in 2010, replaced by a more
locally middle-out approach ( followed by individual NHS Trusts), while in the USA,
although the bottom-up approach was initially adopted, nowadays it is moving toward a
middle-out approach (Morrison et al., 2011). Moreover, in Germany, integrated personal
health system efforts are currently not driven by the state and since there is no central
infrastructure to support them, the numerous small local initiatives constitute a bottom-up
approach (Bratan et al., 2013).
However, what is more important is to examine the reasons why each country has chosen
the specific EHR implementation approach. As can be seen in Table I, political reasons are
the predominant reason, for 9 out of the 13 countries, for choosing the specific
implementation approach.
4.3 Main difficulties during the EHR implementation process
Next, in line with the results of the work of Deutsch et al. (2010), it was found that the major
difficulty in the EHR implementation process is users’ acceptance of the new system
(Table II). Users’ acceptance is not only the most frequent choice but, also, the most highly
rated one. On the other hand, although Deutsch et al. suggest that “funding” is an equally
critical issue to “acceptance,” the results of the current study do not confirm this perception.
More specifically, “EHR project funding” is not so highly ranked and it is reported as the
fifth most important difficulty (Table II) (in line also with the results presented in Table I).
Another difference among the two research studies is that “interoperability standards” is
displayed in third place in Table II, while in the research of Deutsch et al., it is the least
DK UΚ CH CA US IL NZ KO DE SE NO AU NL
Table II.
Main difficulties
during the EHR
implementation
process
Users’ acceptance
(4) (4)
(5) (5)
(3) (5)
(5)
(5)
Project management
(4)
(4)
(5) (5)
(3)
(4)
Interoperability standards
(4)
(4) (3) (5) (4)
(4)
Data protection and safety
(5)
(5) (4)
(4)
EHR project funding
(4)
(4)
(3) |
Technical architecture – network connection
(4)
Health policies
(3)
Notes: Countries having adopted the middle-out, bottom-up and top-down approach. Tick symbol (|)
denotes participant’s selection. Blank space indicates that no answer was provided. Numbers indicate the
level of importance of each reason (1 ¼ slightly important, 2 ¼ fairly important, 3 ¼ important, 4 ¼ quite
important, 5 ¼ very important)
important. “Project management” was ranked second most important and most frequently
reported factor in Table II but in Deutsch et al., research is ranked third.
Turning the attention to ways of overcoming these difficulties (Table III), “apply
modifications to current EHR software,” “information campaigns tailored to users’ needs”
and “governmental act” are proposed as the most significant options.
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EHR
4.4 Critical success factors for EHR system implementation
In the same line, “commitment and involvement of all stakeholders” is considered from all
participants as the most critical success factor for the implementation of an NEHR system
(Table IV ). “Clear long-term perspectives, endurance, and patience” is considered as the next
critical factor from ten participants. Similarly, ten participants suggest that good organizational
change management, interdisciplinary teams with IT experience and clear incentives are
important success factors of EHR system implementation. Commitment and involvement of
medical staff is also considered as a very important success factor, since six out of the eight
experts who have select this factor have rated it with five, in the 1-5 rating scale. The key
factors displayed in Table IV were based on eHealth IMPACT study, which demonstrates the
potential of eHealth as an enabling tool for meeting the “grand challenges” of European health
delivery systems, and was financed by the European Commission, Directorate General
Information Society and Media, ICT for Health Unit (Stroetmann et al., 2006).
123
DK UΚ CH CA US IL NZ KO DE SE NO AU NL
Apply modifications to current EHR software (5) (4)
(4) (5) (4)
(5)
(5) |
Information campaigns tailored to users’ needs
(5) (3) (3) (4)
(5)
(4)
Governmental act
(1)
(5)
(5) (5)
Change project management
(5)
(3)
Replace current EHR software
|
Notes: Countries having adopted the middle-out, bottom-up and top-down approach. Tick symbol (|)
denotes participant’s selection. Blank space indicates that no answer was provided. Numbers indicate the
level of importance of each reason (1 ¼ slightly important, 2 ¼ fairly important, 3 ¼ important, 4 ¼ quite
important, 5 ¼ very important)
Table III.
Ways of overcoming
EHR implementation
difficulties
DK UΚ CH CA US IL NZ KO DE SE NO AU NL
C&I of all stakeholders
(4) (5) (5) (5) (5) (5) (4) (5) (5) (4) (4) (4) (5)
Clear long-term perspectives, endurance and
patience
(5)
(3) (5) (5) (4) (4)
(5) (4) (4) (4)
Good organizational change management,
interdisciplinary teams with IT experience and
clear incentives
(5) (4)
(4)
(5) (4) (5) (3) (4)
(4) (4)
C&I of medical staff
(5)
(5)
(4) (5) (5)
(4)
(5) (5)
A strong health policy and clinical management
(4)
(5) (4)
(5) (3)
(4)
Regular analysis of costs, incentive systems
and benefits organizational changes in the
clinical sector
(4)
(4)
(4)
(4) (5)
C&I of administrative staff
(5)
(4) (5)
(5)
C&I of nursing staff
(5)
(4) (5)
(5)
Notes: C&I, commitment and involvement. Countries having adopted the middle-out, bottom-up and
top-down approach. Blank space indicates that no answer was provided. Numbers indicate the level of
importance of each reason (1 ¼ slightly important, 2 ¼ fairly important, 3 ¼ important, 4 ¼ quite important,
5 ¼ very important)
Table IV.
Critical success
factors for EHR
system
implementation
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4.5 Critical failures (barriers) during EHR system implementation
On the other hand, the most critical failure factor in the implementation process of an NEHR
system is the lack of support and the negative reaction to any change from the medical,
nursing and administrative community (Table V ). In contrast to common beliefs, low
budget or poor resources are not considered as very important factors for EHR system
implementation failure. The critical failures (barriers) listed in Table V are based on the
survey conducted by the Medical Records Institute, where the principal barriers of EHR
implementation were determined (as cited by Deutsch et al., 2010).
4.6 Practices to be repeated in a future EHR implementation process
In an attempt to examine what was done properly (best practices), participants were asked
to select or name practices they would repeat in a future NEHR implementation process.
The result (Table VI) shows that although “the commitment at the highest level and the
coordination of IT/business strategies” has attracted a slightly lower rating (34) than the
next two practices, it is considered as the best practice since six out of seven participants
(who have select this practice) have rated it with 5 (very important), in the 1-5 rating scale.
Both “high usability and interoperability or integration based on standards taking basic
legal requirements into account” (three out of eight have rated it with 5) and “aligning
functionality with user requirements and work processes” ( four out of eight have rated it
with 5) were recommended from eight experts in total and have collected the same rating
(35). Other less (but still) important practices are: “understanding of the culture of the health
sector, as well as the use of an evolutionary approach” and “project management.”
These practices that were proposed to the experts (listed in Table VI) were based on the
Brender et al. (2006) study concerning the factors that influenced the success and failure of
health informatics systems.
5. Discussion
The adoption of the appropriate NEHR implementation approach plays a crucial role as far
as system development time and budget for each country is concerned.
DK UΚ CH CA US IL NZ KO DE SE NO AU NL
Table V.
Critical failures
(barriers) during
EHR system
implementation
Too little support and negative reaction to any
change from the medical, nursing and
administration staff
(5) (4)
(3)
(5) (5)
(3)
(5) (5)
No clear goals and lack of functionalities
really needed
(5)
(5)
(5) (5)
Quality of EHR systems available
(2) (4)
(4)
(4) (4) (2)
Total underestimation of the level of
complexity
(5)
(4)
(4)
(4)
Emergence of fragmented solutions
(4)
(4)
(4)
Creation of a strong business case (ROI)
(2)
(5) (4)
Finding an EHR solution that fulfills one’s own
requirement
(5)
(5)
Migration from paper-based to electronic files
(4)
(5)
High costs of EHR system
(3)
(4)
Difficulty to evaluate appropriate EHR
solutions or components
(4)
Low budget/poor resources
(4)
Notes: Countries having adopted the middle-out, bottom-up and top-down approach. Blank space indicates
that no answer was provided. Numbers indicate the level of importance of each reason (1 ¼ slightly important,
2 ¼ fairly important, 3 ¼ important, 4 ¼ quite important, 5 ¼ very important)
DK UΚ CH CA US IL NZ KO DE SE NO AU NL
Commitment at the highest level and
coordination of IT/business strategies
(5) (5)
(5)
(5) (5)
(4) (5)
High usability and interoperability or
integration based on standards taking basic
legal requirements into account
(4) (5) (4) (5)
(4)
(4) (4) (5)
Aligning functionality with user requirements
and work processes
(4) (4) (4) (3)
(5)
(5) (5) (5)
Understanding the culture of the health sector
and an evolutionary approach
(4) (5) (5)
(5) (5) (5)
(4)
Project management
(4) (4)
(5) (5) (5) (5)
(4)
Willingness to change, intensive
communication, training of and cooperation
between IT and other persons involved
(5) (4)
(5) (5) (4)
Adequate cost-effectiveness, benefits and funding
(4)
(5)
(5) (3) (5)
Notes: Countries having adopted the middle-out, bottom-up and top-down approach. Blank space indicates
that no answer was provided. Numbers indicate the level of importance of each reason (1 ¼ slightly important,
2 ¼ fairly important, 3 ¼ important, 4 ¼ quite important, 5 ¼ very important)
5.1 EHR implementation approach and healthcare systems funding
The results show that the “middle-out” approach is the predominant approach adopted by
almost all the non-European countries. On the other hand, three of the European countries
have adopted the top-down, while three more the bottom-up approach. It is not clear whether
this is related to the funding body (as it is shown in Table I) or not, but it is obvious that the
countries where EHR implementation is funded by the state have adopted either the
top-down or the bottom-up approach. Furthermore, the selection of the implementation
approach is probably influenced by each country’s administrative structure. For example, in
Norway and Sweden, where the healthcare system is considered decentralized, while county
councils are responsible for the organization and provision of healthcare services (Thomson
et al., 2013), the bottom-up approach is followed. Similarly, Switzerland, which consists of
26 cantons that are responsible for licensing providers vendors, hospital planning and the
subsidizing of institutions and organizations (Thomson et al., 2013), has also chosen to adopt
the bottom-up implementation approach. However, regardless of the NEHR implementation
approach followed, the establishment of a unique patient identifier on a national level is an
important priority, where 9 out of 13 countries already using it (as illustrated in Table VII).
5.2 Issues and considerations during the EHR implementation process
A business architecture director has stated that “the political imperative came from
frustration and lack of local activity.” Moreover, it was also proposed by a CTO that “overall
strategy and definition of the EHR” is another quite important reason. Furthermore, the
same expert insists that special consideration should be given to current and legacy
systems. A project leader and senior clinical informatics specialist stated that it is easy to
underestimate the complexity of healthcare and how the system needs to respond.
Apart from the difficulties in implementing EHR systems, more issues emerged from the
comments made by a CTO. These issues are the EHR adoption and use by clinicians, the
EHR implementation cost, the EHR system productivity and, also, the training for using an
EHR system. Furthermore, as the CTO underlines, all projects are taking longer than
expected to be developed and implemented, while sometimes analysis-paralysis
phenomenon arises. It was also suggested that a more step-by-step approach in the
release of the new system should be followed.
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Table VI.
Practices to be
repeated in the future
EHR implementation
process
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126
Table VII.
Unique personal
identifier usage
Country
Personal
identifier
Denmark
Yes
Comments
A unique electronic personal identifier exists for every Danish citizen, which
is used in all health databases
The UK
Yes
The NHS number assigned to every registered in the UK is considered as a
unique personal identifier
Switzerland
Yes
Each Swiss resident holds a personal identification number
Canada
No
There is no national patient identifier
The USA
No
Absence of a universal patient identifier
Australia
Yes
Each person has a unique personal identifier
New Zealand
Yes
Every person using health services has a national health index number
which is used as a unique identifier
Israel
Yes
Each citizen has a unique patient identification number
Korea
No
There is no unique patient identifier that can be used only for
medical purposes
Germany
No
Absence of a unique patient identifier
Sweden
Yes
Every Swedish has a personal electronic identity number
Norway
Yes
All residents in Norway are assigned a unique personal identification number
Austria
Yes
Patient’s social insurance number is considered as the unique patient identifier
The Netherlands Yes
All Dutch patients have a unique identification number
Note: Countries having adopted the middle-out, bottom-up and top-down approach
5.3 Ways of overcoming EHR implementation difficulties
Information campaigns, as a way of overcoming EHR implementation difficulties, should
also be directed at doctors and not only to patients, because they also need persuasion in
order to accept a new EHR system, as was noted by a business architecture director.
It should also be stressed that a project manager has recommended two more ways of
overcoming EHR implementation difficulties (“the inclusion of different actors” and “the
integration of stakeholders” – both rated as “very important”). Finally, another participant,
the director of a national organization for EHR implementation, suggested that most
difficult situations will be resolved over time with the adoption of good project management
practices and processes reengineering.
5.4 Success factors for EHR system implementation
More success factors that were considered important and were proposed by the experts are:
industry support (proposed by a project manager), benefit for professionals (proposed by a
chairman) and the solution must provide early benefits for many stakeholders (not only to
the fund provider) (proposed by a director of a national organization for EHR
implementation). Another project manager commented that the administrative staff will
be the key in the successful implementation process, since they will be required to equally
support all the users of the new system. Another condition for success is to ensure
continuous engagement and a productive dialogue between clinical and administrative
users on the one hand, and ICT experts on the other, taking into account that the only
people who can help identify the requirements and modifications needed to an ICT system
are the users, themselves (Brender et al., 2006).
Another aspect that was raised by a CTO was that a more evolutionary approach
in funding should be followed, and that IS funding should be guaranteed for every
province. Furthermore, it is necessary for healthcare administrators to evaluate EHR
benefits and disadvantages to strengthen efficiency, lower costs and improve patient care
(Tsai et al., 2014).
5.5 Barriers during EHR system implementation
A CTO mentioned the fact that the community office physicians are not familiar or trained
to interoperate with an EHR. Clinicians, as IT users, are not well prepared to express their
requirements, with respect to EHR functionality and interoperability. This occurs because
healthcare professionals, who are essential users of eHealth systems, are too often not
sufficiently involved in the implementation process (Lluch, 2011).
Furthermore, a project manager argues that fragmented systems do speed up
departments’ processes, but may cost more in the production phase. Finally, a business
architecture director underlines that technical and functional issues can be sorted out,
but without the confidence and support of users, the system will never be used.
Moreover, another project manager also highlighted that it is not always preferable
to align IT systems with current work processes but, sometimes, work processes need to
be aligned with IT systems. Otherwise, the full value of the IT systems used cannot
be captured.
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127
5.6 Strengths of the research
Introducing a nationwide EHR system requires a huge amount of change for different
stakeholders. These changes depend, to a large extend, on the implementation approach
that each country decide to adopt. Taking into account the heterogeneity of each country’s
financing mechanism, health system and health IT infrastructure, along with the
characteristics of the participated countries, this research offers an overview of what/why/
how has been achieved by other countries and offers some general guidelines to the
countries that intend to implement new NEHR, proposing useful suggestions concerning
the proper and more relevant implementation approach. Another strong point of the
current research is the inclusion of experts from a number of countries (13) spanning
in four continents. Furthermore, bearing in mind that EHR development is very diverse in
each country, this research identifies some common barriers, success factors and best
practices stemming from the experience obtained from many countries, with a sense of
unification and not of comparison (Table VIII).
Countries
Difficulties – barriers of EHR implementation process
Users’ acceptance
Project management
Interoperability standards
Success factors for EHR system implementation
Commitment and involvement of all stakeholders
Clear long-term perspectives, endurance and patience
Good organizational change management, interdisciplinary teams with IT experience and clear
incentives
Commitment and involvement of medical staff
Best practices in EHR implementation process
Aligning functionality with user requirements and work processes
High usability and interoperability or integration based on standards taking basic legal
requirements into account
Commitment at the highest level and coordination of IT/business strategies
Understanding the culture of the health sector and an evolutionary approach
Good project management
8
6
6
13
10
9
8
8
8
7
7
7
Table VIII.
Common results
to most countries
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5.7 Limitations of the research
Although the current research has been conducted to four continents (Europe, North-America,
Oceania and Asia) with the participation of more than 13 countries, the results could not be
generalized, since the characteristics of the health system, as well as the strategic target,
significantly differ from country to country. Furthermore, despite the fact that the participants
of this survey belong to different stakeholder group, it would be necessary to add some more
experts (with various roles in the NEHR implementation process) in order to enhance the
representativeness of the sample and the validity of the findings. Finally, additional
structured interviews should be carried out in order verify the research findings.
6. Conclusions
In the current research, experts from 13 countries (eight from Europe and five from the rest
of the world) have provided some useful insight, as far as the NEHR implementation process
is concerned. Considering the limitations of this research, especially the heterogeneity
amongst the participated country’s healthcare systems and the limited representation of the
stakeholders, this research can be used as a reference point for other countries that intend to
proceed in NEHR system implementation for issues concerning: the EHR implementation
approach to follow, the main difficulties and how to overcome them during the
implementation process and the critical success factors and critical failures – barriers.
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About the authors
Leonidas L. Fragidis received the BSc Degree in Computer Science and the MSc Degree in
Communication System from the University of Wales, Swansea, UK, He received another MSc Degree in
Finance and Financial Information Systems from the University of Greenwich, UK. He is an IT
Professional and a PhD candidate in Democritus University of Thrace, Xanthi. His research interests
include health information systems, eHealth, electronic health record implementation, eEducation, quality
assurance in higher education, wed development and software engineering. His work has been published
in Health Policy and Technology, Technology and Health Care and Scientometrics. Leonidas L. Fragidis is
the corresponding author and can be contacted at: lfrangid@pme.duth.gr
Prodromos D. Chatzoglou is a Professor of MIS and Business Decisions in the Department of
Production and Management Engineering, Democritus University of Thrace, Xanthi, Greece.
He received a BA Degree in Economics from Graduate Industrial School of Thessaloniki, Greece, an
MSc Degree in Management Sciences and a PhD Degree in Information Engineering both from UMIST,
Manchester, UK. His research interests include IS project management, requirements engineering,
health information systems, knowledge management, e-Business and strategic management. His work
has been published in Information Systems Journal, Decision Sciences, International Journal of Medical
Informatics, International Journal of Human Resource Management and Computers and Education.
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