Strategies to Better Understand EHR Implementation Barriers

Item response theory surveying has proven effective in identifying and understanding EHR implementation barriers.

By Sara Heath on

In order to successfully assess EHR implementation barriers across the industry, health IT professionals must effectively survey healthcare organizations. According to a recent study published in the American Journal of Managed Care, item response theory proves to be an effective survey technique.

The research team sought to determine the best strategy for identifying EHR implementation barriers and assessing which is the most challenging. According to the researchers, this is an important step in framing policymakers’ and health IT professionals’ plans for EHR adoption.

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The team did this by looking at three different survey techniques: one that requires respondents to select all barriers that apply to them, one that uses a logistic regression model, and one that uses item response theory (IRT).

With the first option, the researchers found challenges determining which implementation barrier was the most difficult. In these surveys, analysts tend to rank barriers based on which was most frequently cited, a measure the researchers say is inadequate.

“Although this approach is likely to capture how common an issue is among hospitals, it does not explicitly address how difficult a specific challenge is,” the researchers wrote. “Moreover, using response frequencies as a proxy measure for EHR implementation difficulty may lead to inaccurate inferences about the areas where managers should focus their efforts.”

For example, the American Hospital Association’s annual health IT survey uses this polling technique. In the 2013 edition of this survey, the most commonly cited challenge in implementing EHR technology was cost of the technology. However, this might not be the most challenging barrier hospitals face; it could simply be a popular but easily overcome challenge.

Logistic regression models likewise proved inefficient, the researchers reported. In logistic regression models, survey analysts put responses in context of an end goal. For example, the researchers looked at a survey that asked respondents about the biggest barriers to EHR implementation in light of meaningful use attestation.

While this gleaned valuable information for providers working toward successful meaningful use attestation, it does not uncover the practice-wide barriers to a successful EHR implementation.

“Although the Meaningful Use attainment measure can be used as proxy for EHR implementation difficulty, it did not assess the underlying organizational capabilities and resources that make some barriers more difficult than others for a particular hospital,” the researchers said.

“Therefore, having a means of assessing organizational barriers/challenges that does not require other constructs to be fully identified allows for alternative explanations as to why some EHR implementation challenges are greater than others.”

IRT offers a more efficient method for assessing barriers to implementing EHR technology:  an idea of which barrier is most difficult to overcome. By identifying which barriers are most difficult – not most common – organization leaders can better target their implementation efforts.

For example, the IRT survey found that physician buy-in was the most difficult barrier to EHR implementation. However, as noted above, the AHA survey found that technology cost was most common and physician buy-in was the third most common.

According to the researchers, identifying this difference opened the opportunity for organization leaders to develop a better implementation plan.

This is especially important because of how challenging and time-consuming it may be to create widespread provider buy-in for EHRs.

“Changing the culture of the medical community is a far more difficult undertaking than funding EHR purchases and implementations,” the researchers asserted. “To alter the physician community’s beliefs, it may be necessary to start while physicians are in medical school. Such a transformation would take a generation to implement. Ongoing organizational training may help to improve EHR acceptance.”

According to the researchers, these findings have serious implications for the healthcare industry. As governing bodies such as ONC issue guidance on overcoming EHR implementation obstacles, it will be important that they use the most useful information possible.

“Having EHR implementation challenge scales that are lacking potential items is an important issue for policy makers,” the researchers concluded. “The ONC funds research into areas that have been identified as impediments to effective EHR use. Lacking accurate and complete feedback from health system administrators diminishes the ONC’s ability to target EHR implementation challenges.”

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