Currently Viewing:
The American Journal of Managed Care February 2012
Nurse-Run, Telephone-Based Outreach to Improve Lipids in People With Diabetes
Henry H. Fischer, MD; Sheri L. Eisert, PhD; Rachel M. Everhart, MS; Michael J. Durfee, MSPH; Susan L. Moore, MSPH; Stanley Soria, RN; Diana I. Stell, RN; Cecilia M. Rice-Peterson, RN, BSN; Thomas D. MacKenzie, MD, MSPH; and Raymond O. Estacio, MD
Daniel O. Scharfstein, ScD; Cynthia M. Boyd, MD, MPH; Jennifer L. Wolff, PhD; and Chad Boult, MD, MPH, MBA
A Dementia Care Management Intervention: Which Components Improve Quality?
Joshua Chodosh, MD, MSHS; Marjorie L. Pearson, PhD, MSHS; Karen I. Connor, PhD, RN, MBA; Stefanie D. Vassar, MS; Marwa Kaisey, BS; Martin L. Lee, PhD; and Barbara G. Vickrey, MD, MPH
Hospital Readmission Rates in Medicare Advantage Plans
Jeff Lemieux, MA; Cary Sennett, MD; Ray Wang, MS; Teresa Mulligan, MHSA; and Jon Bumbaugh, MA
Early Evaluations of the Medical Home: Building on a Promising Start
Deborah Peikes, PhD; Aparajita Zutshi, PhD; Janice L. Genevro, PhD; Michael L. Parchman, MD; and David S. Meyers, MD
Identifying Patients With Osteoporosis or at Risk for Osteoporotic Fractures
Yong Chen, MD, PhD; Leslie R. Harrold, MD, MPH; Robert A. Yood, MD; Terry S. Field, DSc; and Becky A. Briesacher, PhD
Care by Cell Phone: Text Messaging for Chronic Disease Management
Henry H. Fischer, MD; Susan L. Moore, MSPH; David Ginosar, MD; Arthur J. Davidson, MD, MSPH; Cecilia M. Rice-Peterson, RN, BSN; Michael J. Durfee, MSPH; Thomas D. MacKenzie, MD, MSPH; Raymond O. Estacio, MD; and Andrew W. Steele, MD, MPH, MSc
Systematic Review of the Impact of Worksite Wellness Programs
Karen Chan Osilla, PhD; Kristin Van Busum, MPA; Christopher Schnyer, MPP; Jody Wozar Larkin, BSN, MLIS; Christine Eibner, PhD; and Soeren Mattke, MD, DSc
Adaptation and Psychometric Properties of the PACIC Short Form
Katja Goetz, PhD; Tobias Freund, MD; Jochen Gensichen, MD, MA, MPH; Antje Miksch, MD; Joachim Szecsenyi, MD, MSc; and Jost Steinhaeuser, MD
Currently Reading
EHRs in Primary Care Practices: Benefits, Challenges, and Successful Strategies
Debora Goetz Goldberg, PhD, MHA, MBA; Anton J. Kuzel, MD, MHPE; Lisa Bo Feng, MPH; Jonathan P. DeShazo, PhD, MPH; and Linda E. Love, LCSW, MA

EHRs in Primary Care Practices: Benefits, Challenges, and Successful Strategies

Debora Goetz Goldberg, PhD, MHA, MBA; Anton J. Kuzel, MD, MHPE; Lisa Bo Feng, MPH; Jonathan P. DeShazo, PhD, MPH; and Linda E. Love, LCSW, MA
Small primary care practices reap some organizational and quality of care improvements from electronic health records; however, challenges persist in achieving meaningful use standards.
Difficulties with EHR upgrades and systems failures are a concern, especially for practices without extensive technical support. Practices experienced occasional EHR system or server crashes, which cause major disruption to office operations and patient care. Physicians and staff also reported that some processes take more time using the EHR, the system does not adequately track patients and diseases, and the system does not meet all practice needs. Physicians and staff also repeatedly described their EHR systems as complex, too many functions to navigate, numerous steps needed to complete a transaction, and difficult to customize. Complexity of systems led to problems understanding how to utilize functions and how to incorporate these functions into day-to-day patient care and office operations.

Successful Strategies

Another goal of our study was to identify successful strategies that practices use to overcome these challenges (Figure).

Plan for Work Transition

Practices that experience smoother transitions in implementing advanced EHR functions plan for changes in roles and responsibilities, redesign work processes, and develop up-to-date policies and procedures. This was seen in health system–owned practices as well as in independent practices. One physician described the necessity of work flow protocols for updating medication information on patients in the EHR:

“Protocols for the nurses, the med reconciliations, I mean, that’s huge... what a...potential liability it is if you don’t have the meds right.”

Ensure Adequate Technical Support

Technical support stood out as a critical factor in basic and advanced use of the EHR. Technical support is needed for handling system failures and EHR upgrades, configuring new functions, training staff, customizing templates and other EHR features, and solving day-to-day issues. Practices that are part of larger healthcare systems have more internal access to technical support, such as a formal HIT department, than do independent practices. Independent practices use multiple methods to obtain technical support including: vendor contracts, regional extension center (REC) assistance, peer communication, and in-house expertise, such as an informal EHR “go-to person.”

Operate as a Team

Practices use various team-based methods for incorporating advanced EHR functions that allow physicians to focus on patient care. One practice, part of a large healthcare system, developed a team-based care model that utilized nurses for collecting and entering most patient information into the EHR. An independent practitioner in the study hired a scribe to enter information into the EHR during and after patientcare visits. Other practices developed new roles and responsibilities for team members to enter and retrieve patient-care data from the EHR.

Invest in Training and Communication

Practices successfully using advanced EHR functions dedicated time and resources for training and communication of how to utilize new functions for patient care and improvement efforts. Multiple communication methods, such as group training, train-the-trainer, procedural “work flow” manuals, 1-on-1 guidance, and electronic resources were used to convey purpose of the new EHR function, roles and responsibilities, and instructions for system use. Several practices stressed the need for well-trained nurses and medical assistants from allied health schools for EHR activities and team-based care.


Our case studies suggest that despite incredible advances in computer technology over the past few decades, contemporary concerns about EHRs are similar to those identified earlier: inability to meet practice needs, disruption of work flow,18 a dramatic increase in clerical tasks,19 and inadequate return on investment.20

Practices that have well-established EHR systems readily acknowledge benefits, such as improvements in storage and retrieval of patient information. However, few fully benefit from the interoperability or quality-improvement features that such systems could provide.21-24 Limited use of HIT quality-improvement features may help explain the growing body of evidence that EHR adoption alone does not guarantee improved care.25-30 Quality can be improved if advanced features of EHRs are consistently and effectively utilized,31 such as physician alert and reminder systems,32-34 and performance tracking. In our study, those that used higher level functions of EHRs demonstrated improvements in chronic disease management and preventive service delivery.

Accomplishing the goals set forth by the HITECH Act requires internal practice changes such as dedicated use of advanced EHR functions and significant modifications to work processes at the primary care practice level. Creating and sustaining highly functional teams can facilitate the move toward achieving the most benefit from these new technologies. Transition planning (ie, planning in advance for how basic processes in the office will change), including redesigning roles of individuals and work processes, responding to system interruptions, and incorporating upgrades in ways that are least disruptive, is key. Practices will also need to increase communication and training for employees and physicians, create alternative strategies for patient care during system implementation and upgrades, and formally develop new processes and procedures for provision of care and office operations. Other keys to the adoption and meaningful use of advanced EHR functions include understanding the role technology plays in primary care practice transformation for patientcentered care, how to implement and efficiently utilize the EHR, and obtaining outside financing if needed.

External technical and financial support is also critical for practices to overcome challenges in the adoption and use of advanced EHR functions. There are crucial differences in the ability of independent primary care practices to adopt and utilize EHRs for quality improvement compared with practices that are owned and operated by large healthcare systems. These practices will need additional support from outside sources. Federal and state regulators should continue to support practices by providing financial incentives, grants, and loans to practices. At the regional level, technical assistance from RECs and information-sharing between practices and other healthcare organizations are key facilitators for the adoption and use of advanced EHR functions.


We gratefully acknowledge assistance provided by Rita Pickler, PhD, RN, PNP-BC, FAA N, and Stephen S. Mick, PhD, for guidance and advice provided during this project.

Author Affiliations: From Department of Health Policy (DGG, LF), George Washington University, Washington, DC; Department of Family Medicine (AJK), Department of Health Administration (JPD), School of Social Work (LEL), Virginia Commonwealth University, Richmond, VA.

Funding Source: This study was funded by the Agency for Healthcare Research and Quality, United States Department of Health and Human Services.

Author Disclosures: The authors (DGG, AJK, LBF, JPD, LEL) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DGG, AJK, LBF); acquisition of data (DGG, AJK, LBF, LEL); analysis and interpretation of data (DGG, AJK, LBF, JPD, LEL); drafting of the manuscript (DGG, AJK, LBF, JPD, LEL); critical revision of the manuscript for important intellectual content (DGG, LBF, JPD); obtaining funding (DGG); administrative, technical, or logistic support (DGG, JPD, LEL); and supervision (DGG).

Address correspondence to: Debora Goetz Goldberg, PhD, MHA, MBA, George Washington University, Center for Healthcare Quality, 2121 K Street, Ste 200, Washington, DC 20037. E-mail:
1. Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American
Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5 (Feb. 17, 2009). html. Accessed May 15, 2011.

2. Centers for Medicare & Medicaid Services. CMS EHR meaningful use overview. Use.asp. Accessed January 7, 2011.

3. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-52.

4. Furukawa MF. Electronic medical records and efficiency and productivity during office visits. Am J Manag Care. 2011;17(4):296-303.

5. Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010;17(1):78-84.

6. Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B. Measuring the medical home infrastructure in large medical groups. Health Aff (Millwood). 2008;27(5):1246-1258.

7. Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Serv Res. 2010;6(10):231.

8.Valdes I, Kibbe DC, Tolleson G, Kunik ME, Peterson LA. Barriers to proliferation of electronic medical records. Inform Prim Care. 2004;12(1):3-9.

9. Menachemi N, Burke D, Brooks R. Adoption factors associated with patient safety-related information technology. J Healthc Qual. 2004;26(6):39-44.

10. Gadd CS, Penrod LE. Dichotomy between physicians’ and patients’ attitudes regarding EMR use during outpatient encounters. Proc AMIA Symp. 2000:275-279.

11. Gadd CS, Penrod LE. Assessing physician attitudes regarding use of an outpatient EMR: a longitudinal, multi-practice study. Proc AMIA Symp. 2001:194-198.

12. Dansky KH, Gamm, LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready? J Healthc Manag. 1999;44(6):440-454.

13. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752.

14. Bryan C, Boren SA. The use and effectiveness of electronic clinical decision support tools in the ambulatory/primary care setting: a systematic review of the literature. Inform Prim Care. 2008;16:79-91.

15. Romano MJ, Stafford RS. Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Arch Intern Med. 2011;171(10):897-903.

16. Hsiao C-J, Hing E, Socey TC, Cai B. Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates. In: Statistics NCfH, ed. Hyattsville, MD: Centers for Disease Control and Prevention; 2010.

17. Goldberg DG, Kuzel, AJ. Elements of the patient-centered medical home in family practices in Virginia. Ann Fam Med. 2009;7(4):301-308.

18. Friedman RB, Gustafson DH. Computers in clinical medicine, a critical review. Computing in Biomedical Research. 1977;10(3):199-204.

19. Schwartz WB. Medicine and the computer. N Engl J Med. 1970;283(23):1257-1264.

20. Rind DM, Safran C. Real and imagined barriers to an electronic medical record. Proc Annu Symp Comput Appl Med Care. 1993:74-78.

21. Burt CW, Hing E. Use of computerized clinical support systems in medical settings: United States, 2001-03. Adv Data. 2005;(353):1-8.

22. Weingart SN, Massagli M, Cyrulik A, et al. Assessing the value of electronic prescribing in ambulatory care: a focus group study. Int J Med Inform. 2009;78(9):571-578.

23. Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-311.

24. Robeznieks A. Good news and bad news.:EMR financial gains high, quality gains low: study. Mod Healthc. 2005;35(40):38.

25. O’Connor PJ, Crain AL, Rush WA, Sperl-Hillen JM, Gutenkauf JJ, Duncan JE. Impact of an electronic medical record on diabetes quality of care. Ann Fam Med. 2005;3(4):300-306.

26. Miller RH, Sim I. Physicians’ use of electronic medical records: barriers and solutions. Health Aff (Millwood). 2004;23(2):116-126.

27. Metlay JP, Cohen A, Polsky D, Kimmel SE, Koppel R, Hennessy S. Medication safety in older adults: home-based practice patterns. J Am Geriatr Soc. 2005;53(6):976-982.

28. Wachter RM. Expected and unanticipated consequences of the quality and information technology revolutions. JAMA. 2006;295(23):2780-2783.

29. Kuehn BM. IT vulnerabilities highlighted by errors, malfunctions at veterans’ medical centers. JAMA. 2009;301(9):919-920.

30. Crosson JC, Stroebel C, Scott JG, Stello B, Crabtree BF. Implementing an electronic medical record in a family medicine practice: communication, decision making, and conflict. Ann Fam Med. 2005;3(4):307-311.

31. Blumenthal D. The federal role in promoting health information technology. New York: The Commonwealth Fund Perspectives on Health Reform Brief, 2009. Accessed August 8, 2011.

32. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. J Am Med Inform Assoc. 1996;3(6):399-409.

33. Sequist TD, Gandhi TK, Karson AS, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12(4):431-437.

34. Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of computerized information services: a review of 98 randomized clinical trials. Arch Fam Med. 1996;5(5):271-278.e and the computer. N Engl J Med. 1970;283(23):1257-1264.
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up