Clinical Information System Challenges

When an organization implements a health care information system (HCIS), whether an EMR, CPOE or other system, there are a great many challenges that must be overcome. Wager, Lee and Glaser classify the barriers to implementing a HCIS into four categories: financial, organizational and behavioral, technical and finally security and privacy barriers. Each of these categories has it own challenges and techniques to overcome them, but organizational and behavioral issues present unique challenges as the precise issues can be subjective, hard to quantify, and often involve individual opinions.

Implementing a HCIS can be very costly. Estimates, as old as ten years, place the cost of an electronic health record system at between $15000 to $50000 per physician at the practice. And another 15-20% of the acquisition costs, yearly, for maintenance and support. On top of this, user productivity can be hindered by as much as 15%, as they familiarize themselves with the system during the first few months of adoption. As such, HCIS have gained much greater adoption in large teaching institutions and hospitals, with sufficient capital resources, and less so in smaller, more risk averse practices, with just a handful of doctors. In 2006, CMS and HHS created exceptions to the Stark and antikickback regulations allowing hospitals to open up their health care information systems to physician practices at greatly reduced rates than if they were to implement the systems themselves.

As mentioned earlier, organizational and behavioral barriers to implementing a HCIS can be hard to pin down. They include changes to workflows and SOPs, physician acceptance and even more discrete issues like variations in state licensing. Most EHR and CPOE systems require substantial changes to basic workflows. A physician telling a nurse to order a medication is just as simple as that. But with a CPOE involved, the physician could be encumbered with medication alerts and reminders, all meant to aid in the quality of care. But from the physician’s perspective it could just be slowing them down. Learning the system while trying to accomplish routine health care can frustrating and time consuming. Most of these issues can be handled with proper planning, communication, initial and on-going training and then providing proper evidence the system is aligned and integrated with their patient care workflow. Managing expectations is the key to overcoming most organizational and behavioral barriers to HCIS implementation.

Technical barriers to HCIS implementation encompass how new and emerging technologies integrate with existing systems. Systems must be planned wisely by individuals who understand existing and emerging technologies as well as data definitions and standards. It is the standards and data definitions that allows one system to integrate with another. For example, the standards or data definitions for an EHR vendor must be in synch with those from a CPOE vendor or the systems risk becoming data silos. Poor standards and the rapid advancement of the underlying technology can inhibit the adoption and utilization of a HCIS.

Privacy and security is also a major challenge to overcome when implementing a HCIS. In recent years there has been an increase in identity theft and health care fraud. And even more recently there have been cases of ransomware attacking hospitals . The miscreants encrypt the data systems and will only provide the key once a ransom has been paid (New York Times. 2016). Couple this threat with the financial and criminal penalties for protected health information breaches and it is easy to see why IT security and patient privacy becomes a large concern, even a barrier, when implementing a HCIS.

Implementing a HCIS at a health care organization is fraught with complex issues and problems. Financial issues affect smaller organizations disproportionately due to the generally lower levels of capital. Technical barriers where standards and data definitions are required to have proper interoperability between systems is very important; especially when augmenting an existing system with new emerging technologies. Privacy and confidentiality is also a large barrier to HCIS implementation as we have seen hospitals become specific targets of ransomware. And finally, the most challenging barrier to HCIS implementation is organizational and behavioral. You can lead a horse to water but you can’t make it drink. The key to most all of these barriers is proper planning, design and communication with a constant feedback loop during a phased rollout. If physicians are well aware beforehand, of the productivity hits in the first few months, as well as the overall benefit, they will be more open to such systems. If security is planned into the system from the start and the proper people are involved. People who understand security, standards, data definitions and emerging technologies. And if financial planning it is thought through and evelautated from the beginning, then re-evaluated with a feedback loop during rollout, the chances for successful HCIS implementation will be much greater.

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Wager, K. A., Lee, F. W., Glaser, J. P. (2009). Health care information systems: A practical approach for health care management. San Francisco, CA: Jossey-Bass.

(2016, February 17). Retrieved October 11, 2016, from http://www.nytimes.com/2016/02/18/us/california-hospital-pays-bitcoin-ransom-to-hackers.html