Shiraz E-Med J. 2016 February; 17(2):e33304.
doi: 10.17795/semj33304.
Published online 2016 February 28.
Review Article
The Identification and Classification of Deployment Challenges
Related to Electronic Health Records: A Review Article
Ali Garavand,1 Mahnaz Samadbeik,2 Mojtaba Kafashi,3,* and Shahabeddin Abhari4,5
1
Department of Health Information Technology, Shiraz University of Medical Sciences, Shiraz, IR Iran
Department of Health Information Technology, Lorestan University of Medical Sciences, Khorramabad, IR Iran
Department of Health Information Technology, Fasa University of Medical Sciences, Fasa, IR Iran
4
Health Policy Research Center (HPRC), Shiraz University of Medical Sciences, Shiraz , IR Iran
5
Health Human Resources Research Center, School of Management & Information Sciences, Shiraz University of Medical Sciences, Shiraz, IR Iran
2
3
*
Corresponding author: Mojtaba Kafashi, Department of Health Information Technology, Fasa University of Medical Sciences, Fasa, IR Iran, E-mail: kafashim@gmail.com
Received 2015 October 10; Revised 2016 January 08; Accepted 2016 February 15.
Abstract
Context: The implementation and operation activities related to electronic health records (EHRs) have increased in different countries, and their importance is clear. However, the deployment of an EHR system depends on many factors that must be considered
during implementation. The goal of this study was to identify and classify the challenges related to EHR deployment.
Evidence Acquisition: The present study involved a literature review that was carried out through a search on the ISI, PubMed,
DOAJ, Scopus, Science Direct, and Google Scholar databases, as well as the Google and Yahoo search engines, using the relevant
MeSH keywords and focusing on the period of 2005 - 2015. The data were collected in an Excel file and analyzed based on the study
objectives.
Results: From the investigation of related articles, we found that the deployment of EHRs faces many challenges that can be classified into six main categories. These are economic, behavioral, human, technical, legal, and organizational challenges.
Conclusions: With regard to the obtained results, it is recommended that the authorities put effort into resolving the economic,
behavioral, human, technical, legal, and organizational challenges related to the implementation and deployment of EHRs.
Keywords: Medical Informatics, Health Information Systems, Electronic Health Records
1. Context
In the dynamic environment of health, information
and communication technology (ICT) has played a guiding role and noticeably affected the healthcare pattern at
all levels (1). Health information technology is a combination of medical sciences with information technology
is responsible for the collection, processing, storage, distribution, and sharing of audio files, images, text, and
comprehensive numerical information in electronic form
through use of computer hardware and software to aid in
information communications and decision making (2, 3).
The rapid development of technology and health informatics has encouraged organizations providing healthcare services to acquire the necessary skills to provide advanced and qualified medical services (4). The electronic
health record (EHR) is one of the most widely used technologies in health system; there have been many studies
on this topic in recent years.
EHRs contain all information related to the health of
citizens from before birth until after death; this is gathered
consistently over time and stored electronically. All or part
of the record is available to authorized persons without re-
gard to place or time (5-7). The EHR represents one of the
most ideal healthcare information systems (IS), but it must
be carefully designed and managed according to the needs
of the community (8).
To deploy an EHR, its underlying and preliminary steps
must be well implemented. Table 1 shows the processes involved in creating an EHR system (5, 9).
Failure in each of the above levels listed above can
cause challenges to the deployment of EHRs. Therefore,
after the successful achievement of the first four levels
shown in Table 1, a decision should be made about whether
to implement the EHR system.
Implementation and deployment of EHRs is the ultimate goal of the establishment of information technologies in health systems (9), but this always involves many
barriers and challenges (10-13). Using different viewpoints,
researchers have studied the barriers, acceptance, use, and
continued use, as well as implementation, operation, and
deployment of the EHR system, and have achieved extensive results.
Littlejohns et al. (14) stated that the causes of health information technology use project failure in a hospital in
South Africa were the lack of appropriate infrastructure;
Copyright © 2016, Shiraz University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the
original work is properly cited.
Garavand A et al.
Table 1. The EHR Creation Steps
Level
System Name
Definition
1
Automated medical record
50% of patient information is
produced by computer and
maintained on paper
2
Computerized medical records
Scanning of information into
computers
3
Electronic medical records
(EMRs)
This level is similar to level 2 but
involves making systems
compatible in one hospital
4
Electronic patient records
(EPRs)
The information related to
health care is collected in a
patient-centered manner
5
Electronic health records
(EHRs)
Include all health information
on each person throughout the
lifespan
different expectations of the users, designers, and managers of the project; inattention to cultural features and
the care environment; and an underestimation of the complexity of processes of care. After quantitative and qualitative investigations, the researchers stated that there is
no special difference between the causes of failure in this
project and the reasons for the failure of similar projects
in other countries.
In their study, Langarizade et al. (15) investigated the
technical, organizational, and legal factors related to the
deployment of EMRs and concluded that of five studied
hospitals, three exhibited appropriate readiness; furthermore, in terms of technical requirements, the studied hospitals showed a higher level of readiness.
Ajami et al. (16) stated that a hospital’s for implementation of EHRs has four main scopes, as follows: 1. organizational culture, 2. management and leadership, 3. operational readiness, and 4. technical Readiness. Moreover,
Hostgaard and Nohr (17) concluded that the greatest problem in the implementation of EHRs is organizational culture. Many studies have emphasized training of providers
of care services to promote their individual readiness (18,
19).
Mirani et al. (8) investigated the barriers to implementation of EHRs in Iran, considering the technical, organizational, personal, financial, ethical, and legal factors. They
found that the most important barrier to the implementation of EHRs is the technical barrier. In their study, Jelvay et al. (20) stated that the most important barriers to
the implementation of EHRs are financial and budgetary
barriers, operational barriers, persons’ attitudinal and behavioral barriers, organizational change barriers, technical barriers, legal and ethical barriers, and standardization
barriers. Nematollahi et al. (21) determined that persons’
attitudes and behavior are important in the implementa2
tion of EHRs.
Concerning the importance and development of
health systems and the need for such systems for the
appropriate management and use of healthcare information and to improve the quality of healthcare delivery,
the identification and classification of the EHR implementation challenges and reporting such challenges to
the authorities can lead to organizations effective understanding of their strong and weak points related to the
implementation of the system. It can also help to estimate
their readiness more exactly and perform the appropriate
planning to eliminate these challenges.
If challenges are not considered in the implementation, and this leads to IS failure, this will waste time and
money in the healthcare system. Moreover, the system will
neither be able to develop in a competitive environment
nor deliver healthcare services efficiently. Given the importance of EHRs in providing healthcare services, in this
study, all challenges concerning the method of EHR deployment in previous studies were identified and classified
into groups according to their general dimensions; then,
the independent variables of each group were determined.
In doing this, the goal of the study was to identify and classify the barriers to EHR deployment.
2. Evidence Acquisition
This study is a narrative review study that was carried out with the goal of identifying and classifying the
EHR deployment challenges identified in original research
articles published up to 2015. To perform a comprehensive search, the ISI, PubMed, DOAJ, Scopus, Science Direct,
and Google Scholar databases, as well as Google and Yahoo search engines, were investigated using synthetic keywords.
Figure 1 shows the article search strategy. First, articles published in 2005 - 2015 were searched in the above
databases, and then all retrieved articles in the English language were investigated; articles published in other languages were excluded from study. In the next step, all irrelevant articles were eliminated. After this, review articles,
letters to the editor, short articles, and case reports were excluded. Thus, only original articles remained in the study.
Finally, articles with less than 30 references were excluded.
As a result, 120 articles met the inclusion criteria and were
investigated.
After performing a comprehensive search of the above
databases and considering all inclusion and exclusion criteria, 120 articles remained in the study. The required information from these publications was entered into a selfdesigned checklist consisting of items like the article’s subject, the independent variable and its definition, and deShiraz E-Med J. 2016; 17(2):e33304.
Garavand A et al.
Primary Search in
Databases
(67735443)
Articles not in
to 2015 2005
Period
(64859307)
Elimination of
Articles are not in
English Language
(7293)
Irrelevant Articles
Elimination
(2868282)
Elimination of
Articles are not
Original Research
(397)
Elimination of the
Articles With Less
Than 30 References
(44)
Remained
Articles
(120)
Figure 1. Article Search Strategy
pendent variables related to each independent variable;
then, the information was summarized and reported using the Excel 2007 software based on the research objectives. We coded independent and dependent variables in
our study and entered them into an Excel file to enable easy,
rapid deletion of variables that overlapped with the key
variables.
Shiraz E-Med J. 2016; 17(2):e33304.
3. Results
After performing investigations in six databases and
two search engines (Table 2), 67,735,443 articles were
found. Ultimately, 561 relevant abstracts were selected and
investigated based on the research objectives.
To select articles that were relevant to the study goal,
important keywords that relate to all steps of EHR implementation were used, as shown in Table 3.
3
Garavand A et al.
Table 2. Articles Found in the Databases
Values
Database
Table 4. EHR Deployment Challenges
Number of Articles
Found
Relevant Articles
1
ISI
14,318
42
2
Pub Med
22,338
89
3
DOAJ
550
21
4
Scopus
29,009
76
5
Science Direct
117,228
98
6
Google Scholar
2,520,000
163
7
Google
52,000,000
40
8
Yahoo
15,300,000
32
9
Total
67,735,443
561
Values
Latent Variables
Economic challenges
Purchase or design costs,
cost-effectiveness, efficiency,
budgeting of organization
2
Behavioral challenges
Attitude, adoption and use,
satisfaction, culturalization
3
Human challenges
4
Technical challenges
5
Legal challenges
6
Organizational challenges
Table 3. Relevant Articles Found Based on Combinations of Keywords
Values
1st Keyword
2nd Keyword
Relevant Articles
Found
1
Electronic health
record
Implementation
86
2
Electronic health
record
Challenges
173
3
Electronic health
record
Barriers
121
4
Electronic health
record
Adoption
108
5
Electronic health
record
Deployment
73
Finally, after investigating of 561 available abstracts,
the required information was extracted from 120 relevant
articles; these are listed in Table 4. As shown in this table,
the main variables comprising latent variables were classified into in the six main groups of economic, behavioral,
human, technical, legal and organizational factors, while
variables related to each latent variable were classified as
observed variables.
A latent variable is a variable that cannot be measured
directly; rather, it is measured implicitly through the covariance of two or more observed variables in the identifier role without random error; the observed variable is the
variable set in the identifier role (22).
The result of investigations of the performed studies
showed that successful implementation of health information technology, particularly EHR systems, will be extremely effective in improving the delivery of healthcare
services, reducing costs in the long term, saving time for
physicians and patients, integrating patient information,
and so on (23-26). Nevertheless, for successful implementation of this important technology, requirements, triggers,
4
Observed Variables
1
Awareness, congruency of
individuals’ educations and jobs
with knowledge
Hardware infrastructures, software,
networking, IS, IS support
Confidentiality; IS legal,
information security, and access
levels
Development of IS, ease of use,
policymaker support, integration of
IS, IS standardization, data
interchange standards
and deployment barriers must always be investigated, and
necessary actions must be carried out to resolve any issues.
The results of the comprehensive investigation of the previous studies showed that there are many requirements
in deploying EHR systems, each which requires a separate,
comprehensive investigations. After reviewing the studies, the EHR deployment challenges were classified into six
main groups, namely economic, behavioral, human, technical, legal, and organizational factors. Each type of challenge is affected by many variables, as described below.
3.1. Economic Challenges
This factor includes items like the cost of purchase or
design, cost effectiveness, efficiency, and budgeting. In addition, the cost-effectiveness and efficiency of the system
comprise variables that can be calculated (27). Several studies have identified financial factors as one of the barriers
to EHR implementation (28, 29). For instance, Asadi and
Mastaneh (12) considered economic factors as a driving factor in the use of health information technology. Moreover,
Schleyer (29) stated that failure to obtain return on investment has resulted in the criticism of ICT. In contrast, Rippen and Yasnoff (28) estimated the value of the efficient
use of ICT in healthcare industry at more than $87 billion.
In addition, Jelvay et al. (20) stated that the most important barriers to the implementation of EHRs in Iran are financial and budgetary. In relation to the lack of circumstances for the implementation of EHRs, it seems that one
of the factors must be considered as a barrier, and the necessary actions to resolve them must be carried out. Therefore, authorities and policymakers should review and calculate the necessary financial resources for deployment of
Shiraz E-Med J. 2016; 17(2):e33304.
Garavand A et al.
the EHR system, calculate the cost effectiveness and efficiency of the respective system, and carry out the necessary
actions in order to deploy it.
3.2. Behavioral Challenge
Behavioral challenges include adoption and use, satisfaction, and culturalization. In recent decades, behavioral
factors have been considered in many applications related
to information technology in the health system at various
stages of implementation (30-32). Indeed, behavioral factors relate to individuals’ and communities’ attitudinal
and cultural issues concerning information. Most physicians are reluctant to use computerized information systems and do not express any interest in doing so (33). Rippen and Yasnoff (28) stated that cultural problems and dissatisfaction (behavioral and cultural attitudes) are important in the implementation of ICT in the healthcare system.
In research performed by Mitchell et al. (34) human factors
and acceptance of the new technology by human resources
are the critical factors in the use of information technology. Thus, behavioral factors, including adoption and use,
satisfaction, and culture, have important effects on the deployment of EHRs, and authorities should note behavioral
and cultural issues at both the individual and social levels.
3.3. Human Challenges
This challenge includes awareness, the congruency
of individuals’ educations and job with knowledge, and
other human issues, such as individual factors that affect
the deployment of the EHR. In his review article, Lluch (10)
investigated healthcare specialists as a barrier to the establishment and use of health information technology. Nematollahi et al. (35) stated that holding educational workshops and promoting individuals’ knowledge are effective
in the implementation of EMRs. In addition, other studies
have emphasized the impact of the education and training
of individuals, as well as individual factors, for the implementation of the EHR system (8, 20).
3.4. Technical Challenges
Hardware infrastructures, software, networking, IS,
and IS support are some of the most important items that
should be considered in terms of technical challenges of
EHR deployment. In most performed studies, technical
factors have been investigated extensively (10, 12, 20, 3638). Bagayoko et al. (39) stated that the establishment of
the appropriate hardware and software infrastructures is
one of the prerequisites of the successful use of the IS. Mirani et al. (8) also noted that technical issues represent the
most important barrier to the implementation of the EHR
systems in Iran, and suggested that appropriate technical
measures must be taken to resolve this problem.
Shiraz E-Med J. 2016; 17(2):e33304.
3.5. Legal Challenges
Legal factors include confidentiality and IS legal, information security, and access levels. Because of their immense importance, individuals’ medical records both in
computerized and paper form always have high sensitivity
(21). Therefore, attention must be paid to the legal and ethical issues in the implementation of EHR systems. Sheikhtaheri et al. (40) discussed the importance of patient safety
information systems (PSIS), which require the appropriate
design and implementation in Iran hospitals.
3.6. Organizational Challenges
This challenge includes items like development of IS,
ease of use, policymakers’ support, integration of IS, IS
standardization, and data interchange standards. Indeed,
organizational challenges have always been discussed in
terms of management issues, particularly in the case of
the implementation of EHR. The adoption of medical IS
does not only involve purchasing the required hardware
and software; rather, it is a process of interaction between
users, organizations, and the environment (33).
Bagayoko et al. (39) identified two important prerequisites for the successful use of IS, namely a rigorous and consistent organization of the actors and processes of care in
which they are involved. In the United States, Reid et al. (41)
assessed the role of organizational factors as a disincentive
for the use of ICT. Moreover, Mirani et al. stated that organizational factors represent one of the barriers to the implementation of EHR but that they are less important than
other factors (8). In contrast, Garavand stated that organizational factors represent one of the key factors in EMR deployment (9). Through the preparation of standards and
IS development, the codification of policies, support from
authorities, and precise planning to encounter organizational challenges, this threat can be turned into an opportunity.
Having outlined the six general dimensions introduced in this study and their observed independent variables, these challenges can be presented as shown in Figure 2.
Some studies have investigated the barriers and challenges related to the implementation and deployment
of the EHR from other perspectives than those described
above; therefore, the attempt has been made to build a
model that includes all of the involved items and all challenges that previous authors have considered. The results
of all the performed investigations are shown in Figure 2.
4. Conclusions
With regard to the high volume of data in the health
system and the importance of their use, the adoption of
5
Garavand A et al.
Figure 2. Structural Model of EHR Deployment Challenges
q
q
q
Buy or designing
costs
q
Budgeting
attitude
q
Cost / Efficacy
Adoption and use
q
usefulness
satisfaction
q
q
q
q
culturalization
q
q
q
q
Development of IS
q
Economical
Challenges
Ease of use
q
q
q
q
Policymaker
support
q
Data Interchange
Standards
Organizational
Challenges
Integration of IS
q
Behavioral
challenges
EHR Deployment
Human
Challenges
awareness
q
Knowledgeable
Forces
IS standardization
Congruency of
education and job
q
q
Legal Challenges
q
Infrastructures
hardwares
Technical
Challenges
confidentiality
softwares
Access Levels
networking
IS legal
IS
Information
Security
IS Support
q
q
q
q
q
q
q
q
q
q; questions that about any observed independent variables that can be identified in another studies.
computers and especially EHR systems has become necessary to advance organizational goals. Different challenges
and barriers have been identified for EHR implementation
by many studies investigating EHR deployment and implementation. With regard to the importance of the investigation of barriers and challenges, it is suggested that researchers perform comprehensive studies in this field to
determine the opportunities and risks related to EHR systems.
The results showed that the most important challenges
for EHR are economic, behavioral, human, technical, legal,
and organizational issues. Therefore, it is suggested that
authorities and administrators of EHR implementation in
the Ministry of Health should consider the appropriate
budget for the design, purchase, and establishment of this
system. This will result in higher efficiency and cost effectiveness in the implementation. In addition, various training courses and scientific education in the field of EHR
must be provided to address the attitudinal, cultural, and
6
human factors that may create a challenge for the implementation of EHRs. Furthermore, the Ministry of Health
must generate specific standards to resolve issues relating to legislation, support systems, available hardware and
software, and the other organizational issues, such as the
integration of existing systems.
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