CAH to CAH

Summary

The US government allocated $30 billion to implement electronic health records (EHRs) in hospitals and provider practices through policy addressing Meaningful Use (MU). Most small, rural hospitals, particularly those designated as Critical Access Hospitals (CAHs), comprising nearly a quarter of US hospitals, had not implemented EHRs before. Little is known about implementation in this setting. Socio-technical factors differ between larger hospitals and CAHs, which continue to lag behind other hospitals in EHR adoption.

Objectives: The main objective is to provide EHR implementation advice for CAHs from a spectrum of experts with an emphasis on recommendations from their peers at CAHs that have undertaken the process. The secondary objective is to begin to identify implementation process differences at CAHs v. larger hospitals.

Methods: We interviewed 41 experts, including 16 CAH staff members from EHR teams at 10 CAHs that recently implemented EHRs. We qualitatively analyzed the interviews to ascertain themes and implementation recommendations.

Results: Nineteen themes emerged. Under each theme, comments by experts provide in-depth advice on all implementation stages including ongoing optimization and use. We present comments for three top themes as ranked by number of CAH peer experts commenting – EHR System Selection, EHR Team, and Preparatory Work – and for two others, Outside Partners/Resources and Clinical Decision Support (CDS)/Knowledge Management (KM). Comments for remaining themes are included in tables.

Discussion: CAH experts rank the themes differently from all experts, a likely indication of the differences between hospitals. Comments for each theme indicate the specific difficulties CAHs encountered. CAH staffs have little or no EHR experience before implementation. A factor across themes is insufficient system and process knowledge, compounded by compressed implementation schedules. Increased, proactive self-education, via available outside partners and information resources, will mitigate difficulties and aid CAHs in meeting increased CDS requirements in MU Stages 2 and 3.

Citation: Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. CAH to CAH: EHR Implementation Advice to Critical Access Hospitals from Peer Experts and Other Key Informants. Appl Clin Inf 2014; 5: 92–117 http://dx.doi.org/10.4338/ACI-2013-08-RA-0066

 

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Keywords

Electronic health records - rural hospitals - critical access hospitals - qualitative research - medical informatics.

 

 

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Conflicts of Interest

The authors declare that they have no conflicts of interest in this research.

• References

• 1 US Congress.. American Recovery and Reinvestment Act of 2009. 2009 [cited 2012 August 8]; Available from: http://www.gpo.gov/fdsys/pkg/BILLS-111hr1enr/pdf/BILLS-111hr1enr.pdf.
• 2 Ash JS, McCormack JL, Sittig DF, Wright A, McMullen C, Bates DW. Standard practices for computerized clinical decision support in community hospitals: a national survey. J Am Med Inform Assoc 2012; 19 (06) 980-987. Epub 2012/06/19.
• 3 Flex Monitoring Team [Internet].. About Flex Monitoring Team and Critical Access Hospitals. [updated 2010 May 26; cited 2013 July 16]; Available from: http://www.flexmonitoring.org/aboutcahflex.shtml.
• 4 American Hospital Association.. Fast Facts on US Hospitals From 2011 Annual Survey, AHA Hospital Statistics, 2013 edition. [updated 2013 Jan 3; cited 2013 March]; Available from: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml
• 5 US Census Bureau.. Urban/Rural and Metropolitan/Nonmetropolitan Population: 2000 –United States –Urban/Rural and Inside/Outside Metropolitan Areas. Census 2000 Summary File (SF 1) [cited 2012 March 13]; Available from: http://factfinder2.census.gov/faces/tableservices/jsf/pages/product-view.xhtml?pid=DEC_00_SF1_GCTP1.US93&prodType=table
• 6 Desroches CM, Charles D, Furukawa MF, Joshi MS, Kralovec P, Mostashari F, Worzala C, Jha AK. Adoption of electronic health records grows rapidly, but fewer than half Of US hospitals had at least a basic system. Health Aff (Millwood) 2013; 32 (08) 1478-1485. doi: 10.1377/hlthaff.2013.0308. Epub 2013 Jul 9.
• 7 Wenzlow L. Meaningful Use attestations in 2011: CMS/ONC raw dataset tells hospital story. In: Wisconsin Office of Rural Health online blog, Rural Health IT: What “Meaningful Use” Means to Rural. 2012 January 11 –[cited 2013 March]. Available from: http://www.worh.org/hit/2012/01/meaningful-use-attestationsin-2011-cmsonc-raw-dataset-tells-hospital-story.
• 8 Leily S. Resources for Critical Access Hospitals and small rural hospitals [Internet]. Office of the National Coordinator for Health Information Technology. Weekly Digest Bulletin 2013 March 18.
• 9 Flex Monitoring Team.. Universities of Minnesota, North Carolina-Chapel Hill, and Southern Maine: Flex Program; [updated 30 June 2013; cited March 2013]. Complete list of Critical Access Hospitals (1,331 CAH hospitals, current as of December 31, 2012). Available from: http://www.flexmonitoring.org/cahlis/tRA.cgi.
• 10 Centers for Medicare & Medicaid Services.. Baltimore: CMS; [updated 6 November 2013; cited March 2013]. EH recipients of Medicare EHR incentive program payments 2012. ProvidersPaidByEHRProgram_Dec2012_FINAL_HOSPiTAL.csv. Available from: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/DataAndReports.html.
• 11 Adler-Milstein J, Furukawa MF, King J, Jha AK.. Early results from the hospital electronic health record incentive programs. Am J Manag Care 2013; 19 (07) e273-e284. Epub July 10, 2013.
• 12 World Health Organization.. Geneva: WHO; c 2013 –[cited 20 April 2013]. Directory of eHealth Policies. Keeping Promises, Measuring Results 2011. Available from: http://www.who.int/goe/policies/en/index.html
• 13 Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc 2003; 10 (03) 229-234. Epub 2003/03/11.
• 14 Brender J, Ammenwerth E, Nykanen P, Talmon J. Factors influencing success and failure of health informatics systems - a pilot Delphi study. Methods Inf Med 2006; 45 (01) 125-136. Epub 2006/02/17.
• 15 Aarts J. Understanding implementation: a socio technical appraisal on the introduction of computerized physician order entry systems in Dutch and American hospitals. Rotterdam (Netherlands): Erasmus University; 2005
• 16 Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people. Int J Med Inform 2003; 69 2–3 235-250. Epub 2003/06/18.
• 17 Leviss J. editor. H. I. T. or miss: lessons learned from health information technology implementations. Chicago: AHIMA Press; 2010
• 18 Miller J. editor. Implementing the electronic health record: case studies and strategies for success. Chicago: HIMSS Press; 2005
• 19 Kaplan B, Harris-Salamone KD. Health IT success and failure: recommendations from literature and an AMIA workshop. J Am Med Inform Assoc 2009; 16 (03) 291-299. Epub 2009/03/06.
• 20 Craven CK. Implementation planning processes in Critical Access Hospitals. Columbia, Mo. (USA): University of Missouri; Forthcoming; 2014
• 21 Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R. Overcoming barriers to adopting and implementing computerized physician order entry systems in U. S. hospitals. Health Aff (Millwood) 2004; 23 (04) 184-190. Epub 2004/08/21.
• 22 Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. Experts speak: advice from key informants to small, rural hospitals on implementing the electronic health record system. In: Lehmann CU, Ammenwerth E, Nøhr C. editors. Conducting medical informatics by converging technologies, conveying sciences and connecting people. MEDINFO 2013; Proceedings of the 14th World Congress on Medical and Health Informatics. Series: Studies in Health Technology and Informatics, Vol. 192; 2013 Aug 19–25; Copenhagen, Denmark. Amersterdam:: IOS Press; 2013. p. 608-612
• 23 Ash JS, Smith AC, Stavri PZ. Performing subjectivist studies in the qualitative traditions responsive to users. In: Friedman CP, Wyatt JC. editors. Evaluation methods in biomedical informatics. 2nd ed. New York:: Springer-Verlag; 2006. p. 267-300.
• 24 Saldana J. The coding manual for qualitative researchers. Los Angeles: Sage; 2009
• 25 Health Resources and Service Administration.. Washington: 2010. [cited 2013 May]. HRSA Office of Rural Health Policy. Meaningful Use and Critical Access Hospitals: a primer on HIT adoption in the rural health care setting. Available from: http://www.hrsa.gov/ruralhealth/pdf/meaningfuluseprimer.pdf.
• 26 Centers for Medicare & Medicaid Services.. Baltimore: CMS; [cited 2013 March 10]. Stage 1 vs. Stage 2 comparison table for eligible hospitals and CAHs (2012). Available from: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html.
• 27 Osheroff JK, Kleeberg P, Shank T. Clinical decision support-enabled quality improvement for Meaningful Use. Washington DC: Office of the National Coordinator for HIT Annual Meeting; 2012 Dec; 13
• 28 Davenport T, Prusak L.. Working knowledge: how organizations manage what they know. Boston, Mass.: Harvard Business School Press; 1998
• 29 Davenport TH, Glaser J. Just-in-time delivery comes to knowledge management. Harv Bus Rev 2002; 80 (Suppl. 07) 107-111 126. Epub 2002/07/27.