Develop a realistic set of ROI expectations, including metrics that can be used to accurately estimate and later measure benefits realized and if corrective actions are needed.


Your organization will need to overcome numerous barriers to acquire an electronic health record (EHR). An open discussion about each of the potential barriers goes a long way to overcoming them. The following is a list of barriers and potential ways clinics may overcome them. As you identify additional barriers, add them to the list and discuss specific ways they can be overcome in your clinic. Ensure that all concerns are addressed—no concern is too trivial to be considered.

Some physicians are expected to use an EHR in the hospital in which they practice. Be aware of the differences in barriers and their solutions between the clinic and hospital. Some barriers may be easier to overcome in the clinic. Solutions to the same barrier may vary between the settings.

Barrier Potential Solutions for Clinics
Cost 1. Consider an application service provider/software as a service (ASP/SaaS) offering to lower upfront costs.

2. Plan thoroughly, especially with respect to workflow and process changes. Plan to pre-load data and consider having patients enter some medical history information using utilities for this purpose. These activities will speed the learning curve and decrease the loss of productivity.

3. Take full advantage of all incentives. Use motivational strategies within the clinic to ensure that everyone participates to ensure effective EHR use.

4. Consider following a migration path that first acquires EHR components or EHR-lite products. These may stimulate frustration with their limited functionality or may require conversion to another system in the short term.
Selecting the Right Product 1. For many clinics, an EHR may be the biggest single investment ever made. Many staff members feel ill prepared to make decisions, especially when faced with a marketplace of hundreds of products. Minimize these feelings by reassuring the group that following a formal process makes for better decisions.

2. Follow a formal planning and vendor selection process. Do not underestimate the importance of planning prior to vendor selection. EHRs often are not well understood and planning can help provide education.

3. All certified products will have key functionality, making differentiating factors matters of personal preference. (1.3 Key Differentiators)

4. The key to success is not in selecting the product, but implementing it well. Implementation begins long before selection. Goal setting, studying workflows and processes for improvement, education about EHR, set up, configuration, testing, and training make a greater difference. Evidence shows that two organizations implementing the very same product can have very different outcomes depending on the implementation.
Change 1. Recognize that EHRs will bring about change in workflow and process, including how physicians and other clinicians process clinical knowledge. Set expectations correctly. Many still believe that acquiring an EHR will help solve all problems without having to make any changes, or that an EHR is only an electronic documentation tool, not understanding its enhanced utility. (1.2 Workflow and Process Redesign)

2. Do not underestimate the importance of readiness assessment and planning. Those who have implemented EHRs invariably wish they had spent more time planning.

3. Study current processes and plan for process improvement. Engage all staff, including physicians, in understanding the hassles involved in current processes. When everyone gets actively engaged in making recommendations for change, buy-in to the change is achieved.

4. Make sure everyone is engaged in some way in identifying EHR functional requirements, selecting the right EHR for the clinic, reviewing templates and clinical decision support rules, training, rehearsal for go live, and ongoing optimization.
Learning Curve 1. Anticipate that staff will need time to learn how to use the EHR. Conduct a skills assessment to determine what training is needed. Start early and reinforce early training on computer skills by requiring everyone to use computers for daily functions, such as obtaining patient schedules, retrieving announcements, emailing for internal communications, etc. (1.1 Computer Skills Survey)

2. Introduce clinical guidelines if not already used. Even on paper, guidelines should be reviewed and refined for adoption in the EHR. This process can introduce the concept of templates and clinical decision support that may be resisted by some physicians. This can help develop trust that your EHR’s clinical decision support is based on your own clinicians adopting their own standards of practice.

3. Prepare paper charts for conversion and physicians for the collection of complete clinical data. Adopt or ensure adoption of a complete problem list, medication list, immunization record, allergy information, and any other critical data for the practice. If structured forms to collect this data do not exist, introduce them. Audit records to ensure the key forms have been completed. The forms can then be used to abstract data for populating the EHR in advance so that some data will be available as soon as the system goes live.
Return on Investment (ROI) 1. Develop a realistic set of ROI expectations, including metrics that can be used to accurately estimate and later measure benefits realized and if corrective actions are needed. (1.1 Financial Assessment)

2. Recognize that every clinic will not only have different expectations for ROI, but have different potential for ROI, which tends to be greater when the incremental change is greater. For example, if everyone dictates notes, elimination of a very large percentage of transcription costs can be a significant ROI, but weaning physicians off dictation may be difficult.

3. Count non-monetary forms of benefits in the ROI analysis. The benefit of physicians being able to go home on time, reduced hassles for nurses in handling refill requests, and a sense of providing better quality of care for all can be a powerful motivator for adopting an EHR.
Leadership 1. Ensure that the practice’s physician and administrative leadership are actively behind the EHR. A sole physician champion may sometimes be viewed as a maverick. (1.1 Clinical Leadership)

2. Engage all staff early and often. While the physicians will be paying for the system, lack of staff support can derail success. (1.1 Communications Plan)

3. Ensure that any existing IT staff members are on board. Current IT staff can be intimidated by the complexity of an EHR and distract efforts.
Standards 1. Do not let the lack of adopted standards for fully interoperable systems deter acquisition. Standards take time to be implemented into products, especially when the industry continues to use legacy systems based on older technology. Solid vendors will participate in standards development organizations and often anticipate their adoption even if they are not fully ready for adoption.

2. Standards for data may be more ready for use, but less well adopted than standards for interoperability. Physicians should understand the concepts of controlled vocabularies and appreciate the need for standard rather than proprietary data dictionaries. (2.1 Data Dictionary and e-Discovery, 2.1 Vocabulary)
Privacy and Security 1. Assurance that the system has features and functions that can support HIPAA and HITECH privacy and security requirements is essential. (2.1 EHR Security)

2. Recognize that HIPAA/HITECH security requirements are risk-based and represent minimum expectations. Clinics should consider their business risk and adopt higher standards where possible.

3. Recognize that privacy and security concerns are as much perception as reality. Privacy and security issues must be addressed, as clinicians’ concerns can spill over to patients. A frank discussion with users and patients about protections in place and common-sense practices can go a long way to mitigating potential problems.
Loss of Productivity 1. Recognize that some loss of productivity will be inevitable during the learning curve. Plan for either reduced patient loads or overtime during this time.

2. Seek help not only in learning how to use the system, but in learning potentially new and better ways to communicate with patients. Have patients to perform data entry for you, through a patient medical history portal or kiosks in the clinic, or personal health records.

3. If loss of productivity persists, evaluate processes and workflow to determine whether workarounds to avoid using the computer have been adopted or whether you have true problems with the EHR design or implementation. Correct these quickly and continue monitoring.