Challenges to EHR implementation in electronic- versus paper-based office practices.

BACKGROUND: Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems. OBJECTIVE: To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based). DESIGN: Qualitative study. PARTICIPANTS: Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006. APPROACH: Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0. RESULTS: We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. CONCLUSIONS: Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.

A qualitative analysis of an electronic health record (EHR) implementation in an academic ambulatory setting.

OBJECTIVES: To determine pre-implementation perspectives of institutional, practice and vendor leadership regarding best practice for implementation of two ambulatory electronic health records (EHRs) at an academic institution. DESIGN: Semi-structured interviews with ambulatory care network and information systems leadership, medical directors, practice managers and vendors before EHR implementation. Results were analysed using grounded theory with ATLAS.ti version 5.0. MEASUREMENTS: Qualitative data on perceived benefits of EHRs as well as facilitators and barriers to successful implementation. RESULTS: Interviewees perceived data accessibility, quality and safety measurement, improvement and reporting as benefits of EHR use. Six themes emerged for EHR implementation best practice: effective communication; successful system migration; sufficient hardware, technical equipment, support and training; safeguards for patient privacy; improved efficiency; and a sustainable business plan. CONCLUSIONS: Achieving the benefits of EHRs identified by our interviewees depends on successful implementation and use. Further identification of best implementation practices for EHRs is required, given the financial and clinical consequences of poor implementation.

Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle.

OBJECTIVE: The authors sought to derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. METHODS: The authors prospectively enrolled a convenience sample of patients younger than 18 years of age who presented to the pediatric emergency department of an urban, tertiary care center after sustaining acute twisting injuries of the ankle. The ankle was defined in two regions: the malleolar zone and the midfoot zone. Clinical findings were documented on standardized data collection sheets by faculty physicians before completion of ankle and/or foot radiograph series. Significant fracture was defined a priori as any fracture other than an avulsion < or =3 mm. The authors conducted binary recursive partitioning with cross-validation to develop models to predict fracture. RESULTS: Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81 of 682 (11.9%) and 10 of 173 (5.8%) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100% and specificity of 19.1% on the learning data and 95.1% (95% confidence interval [95% CI] = 87.8% to 98.6%) and 20.0% (95% CI = 16.8% to 23.4%) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100% and specificity of 31.9% on the learning data and 90.0% (95% CI = 55.4% to 99.7%) and 35.0% (95% CI = 27.7% to 42.8%) on the test sample. CONCLUSIONS: A set of sensitive prediction rules was developed to identify children with significant fractures after twisting injuries to the ankle. External validation and refinement of the rules will be needed before recommendation of widespread use.