Fundamental Issues in Implementing an Ambulatory Care Electronic Health Record

Ann Scheck McAlearney, ScD, MS; Jennifer L. Hefner, PhD; Cynthia Sieck, PhD; Milisa Rizer, MD; Timothy R. Huerta, PhD


J Am Board Fam Med. 2015;28(1):55-64. 

In This Article

Abstract and Introduction


Background The use of a fully functional electronic health record (EHR) system is linked to improved quality measures. However, almost half of ambulatory providers with an EHR do not use the full functionality. Attempts to encourage optimal use of EHRs must address barriers associated with the need to change medical practice.

Methods Our primary research question was, what are the fundamental issues associated with the need to change medical practice that created barriers to electronic health record (EHR) implementation and use? In this qualitative study we analyzed the data from 47 interviews with administrative and physician informants and 6 focus groups including 35 practicing physicians across 6 health care organizations that were deemed to be successful with ambulatory EHR implementation.

Results Comments from informants revealed 6 fundamental issues: (1) need to change practice style; (2) threat to professionalism; (3) shift of expertise; (4) required changes to interactions with patients; (5) concern about the impact on medical education and training; and (6) concern about effects on clinical care.

Conclusion The physician experience must be at the forefront of efforts to increase the rate of ambulatory physician use of the full functionalities of an EHR. The issues highlighted here illuminate potential points of intervention when engaging physicians to ensure optimal use of EHRs.


In 2012, 72% of ambulatory physician offices in the United States reported full or partial electronic health record (EHR) use.[1,2] However, only 27% of physicians planning to apply for meaningful use (MU) incentives had EHRs capable of meeting stage 1 core MU objectives.[1,2] Functionalities of EHR systems vary,[3] as does the use of EHR functionalities by individual physicians within a single practice.[4] In 2012 only 40% of US ambulatory care providers used a fully functional system including patient history and demographics, problem lists, physician clinical notes, comprehensive medications and allergies lists, computerized prescription orders, and laboratory and imaging results viewed electronically,[1,5] suggesting that reported use of an EHR in an ambulatory setting cannot be equated with meaningful integration of an EHR into practice. EHR implementation studies must consider how changes in practice patterns and professional concerns could hinder full implementation and integration.

Previous research describes individual and organizational barriers to EHR use.[2,6–9] Organizational barriers include financial costs, potential loss of productivity and therefore income, and lack of standardization across environments.[8,10,11] Frequently cited individual barriers focus on financial, technical, time, psychological, social, legal, and organizational concerns.[12,13] Barriers specific to physicians include participation in EHR selection and planning; physician compensation, that is, effects of EHR use on fee-for-service reimbursement rates;[13] and training time, which may decrease productivity.[14,15] Designing interventions to ameliorate these barriers requires an in-depth understanding of the physician experience. Our study focuses on how the professional life of physicians changes with EHR implementation and how their clinical practice is affected.

Understanding physicians' and administrators' perceptions about the physician experience of EHR implementation is important because of the potential for fully functional EHR systems to reduce costs and improve quality.[2,16] Cost–benefit analyses have documented long-term savings and a slowing of ambulatory care cost growth.[17–19] Providers perceive efficiency and quality of care improvements from electronic patient information exchange that is a component of EHRs.[20] Moreover, quantitative, fully functional EHRs in ambulatory care are associated with significant improvement in provider performance[18,21] and with improved Healthcare Effectiveness Data and Information Set quality measures.[22]

This article describes physician and administrative perspectives about how adoption and implementation of an EHR system affects physicians' clinical practice. The overall goal of this large research study was to improve the understanding of the facilitators of ambulatory EHR system implementation. This article focuses on the barriers physicians face on both a personal and practice level during the adoption and use of such systems. Our primary research question was, What are the fundamental issues associated with the need to change medical practices and physicians' behaviors that create barriers to EHR implementation and use?