ASH, BATES, EHR System Adoption
Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion JOAN S. ASH, PHD, DAVID W. BATES, MD, MSC Abstract
After the ﬁrst session of the American College of Medical Informatics 2004 retreat, during which the history of electronic health records was reviewed, the second session served as a forum for discussion about the state of the art of EHR adoption. Adoption and diffusion rates for both inpatient and outpatient EHRs are low for a myriad of reasons ranging from personal physician concerns about workﬂow to broad environmental issues. Initial recommendations for addressing these issues include providing communication and education to both providers and consumers and alignment of incentives for clinicians. J Am Med Inform Assoc. 2005;12:8–12. DOI 10.1197/jamia.M1684.
This report explores the gap between where we are now concerning adoption of the electronic health record (EHR), where American College of Medical Informatics (ACMI) members believe we should be, why the gap exists, and what can be done about it. The factors and forces inﬂuencing electronic health record adoption in the United States differ between the inpatient and outpatient setting, but the differences represent variations in the strength of the forces rather than the type. Adoption rates are low in both settings, except for speciﬁc sectors. Furthermore, diffusion rates appear to be low. We explore the reasons for this in depth, and present possible strategies for decreasing the inhibiting factors and strengthening the facilitating forces.
Several studies of EHR adoption in the inpatient setting describe rates less than 10%1-3 if computerized physician order entry is used as a proxy for the electronic health record. Usage of systems that display laboratory or radiology results seems to be much more widespread. It could be debated whether CPOE is a reasonable proxy since obviously the EHR exists in many hospitals without CPOE having been implemented and vice versa. However, one might argue that the full advantage of an EHR, which includes decision support, cannot be gained without CPOE. If the decision maker is not the one entering the orders (if, for example, an intermediary like a ward clerk does it) then timely alerts and reminders at the point of care are not possible. For this reason, the EHR with CPOE will be discussed here, and we consider the EHR to also include physician and nursing documentation. Afﬁliations of the authors: Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, OR (JSA); Division of General Internal Medicine, Brigham and Women’s Hospital, Partners Healthcare and Harvard Medical School, Boston, MA (DWB). Correspondence and reprints: Joan S. Ash, PhD, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098; e-mail: . Received for publication: 08/31/04; accepted for publication: 09/21/04.
The results of a 2002 survey1 indicate that 83.7 percent of the hospitals in the United States do not have anything resembling CPOE. The study was a random survey of approximately 1,000 hospitals of the nearly 6,000 listed in the American Hospital Association Guide4 with a 65% response rate. A total of 9.6% responded that they had CPOE fully available, and 6.5% indicated that it was partially available. Since the survey was published, the authors have looked more closely at the kinds of hospitals having full CPOE available, and one third of them are either Veterans Affairs or military hospitals. Therefore, if these government-funded facilities are excluded, approximately 6% of other hospitals have fully implemented CPOE. It is important to include them when discussing CPOE, however, because they are providing models for CPOE implementation that are applicable...