Understanding optimization processes of electronic health records (EHR) in select leading hospitals: a qualitative study

Mark Chun Moon, Rebecca Hills, George Demiris


Background: Little is known about optimization of electronic health records (EHR) systems in the hospital setting while adoption of EHR systems continues in the United States.

Objective: To understand optimization processes of EHR systems undertaken in leading healthcare organizations in the United States.

Methods: Informed by grounded theory approach, a qualitative study was undertaken that involved 11 in-depth interviews and a focus group with the EHR experts from the high performing healthcare organizations across the United States.

Results: The study describes EHR optimization processes characterized by prioritizing exponentially increasing requests with predominant focus on improving efficiency of EHR, building optimization teams or advisory groups, and standardization. The study discusses 16 types of optimization that interdependently produced 16 results along with identifying 11 barriers and 20 facilitators to optimization.

Conclusion: The study describes overall experiences of optimizing electronic health records in select high performing healthcare organizations in the US. The findings highlight the importance of optimizing the EHR after, and even before, go-live and dedicating resources exclusively for optimization.


Electronic health records and systems; Clinical Information systems; Inpatient (inpatient CPOE); System improvement; Facilitators and barriers

Full Text:



McAlearney AS, Sieck C, Hefner J, Robbins J and Huerta TR. Facilitating ambulatory electronic health record system implementation: evidence from a qualitative study. BioMed Research International 2013;2013:629574.

McAlearney AS, Song PH, Robbins J, Hirsch A, Jorina M, Kowalczyk N, et al. Moving from good to great in ambulatory electronic health record implementation. Journal for Healthcare Quality 2010;32(5):41–50. Available from: https://doi.org/10.1111/j.1945-1474.2010.00107.x.

Pandhi N, Yang W-L, Karp Z, Young A, Beasley JW, Kraft S, et al. Approaches and challenges to optimising primary care teams’ electronic health record usage. Informatics in Primary Care 2014;21(3):142–51. Available from: https://doi.org/10.14236/jhi.v21i3.57.

Ash JS, Berg M and Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Journal of the American Medical Informatics Association 2004;11(2):104–12. Available from: https://doi.org/10.1197/jamia.M1471. PMid:14633936; PMCid:PMC353015.

Campbell EM, Sittig DF, Ash JS, Guappone KP and Dykstra RH. Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association 2006;13(5):547–56. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1561794/; https://doi.org/10.1197/jamia.M2042. PMid:16799128; PMCid:PMC1561794.

Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E and Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association 2007;14(4):415. Available from: https://doi.org/10.1197/jamia.M2373. PMid:17460127; PMCid:PMC2244906.

Leventhal R. Trend: EHR optimization. Post-implementation advancements. Leaders from various healthcare organizations explain how they have been moving forward with their EHRs following implementation. Healthcare Informatics 2014;31(2):30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24812989. PMid:24812989.

Terry K. Rev up your EHR: how to optimize performance: learn ways to increase revenue, improve practice efficiency and quality. Medical Economics 2011;88(22):S4.

Baron RJ. Quality improvement with an electronic health record: achievable, but not automatic. Annals of Internal Medicine 2007;147:549–52. Available from: www.annals.org. Available from: https://doi.org/10.7326/0003-4819-147-8-200710160-00007. PMid:17938393.

Desroches CM, Campbell EG, Vogeli C, Zheng J, Rao SR, Shields AE, et al. Electronic health records’ limited successes suggest more targeted uses. Health Affairs 2010;29(4):639. Available from: https://doi.org/10.1377/hlthaff.2009.1086. PMid:20368593.

Ryan A, Bishop T, Shih S and Casalino L. Small physician practices in New York needed sustained help to realize gains in quality from use of electronic health records. Health Affairs 2013;32(1):53–62. Available from: https://doi.org/10.1377/hlthaff.2012.0742. PMid:23297271; PMCid:PMC3864096.

Spetz J, Burgess JF and Phibbs CS. The effect of health information technology implementation in Veterans Health Administration hospitals on patient outcomes. Healthcare 2014;2(1):40–7. Available from: http://www.sciencedirect.com/science/article/pii/S2213076414000062. Accessed 12 December 2015.

Adler-Milstein J, DesRoches CM, Kralovec P, Foster G, Worzala C, Charles D, et al. Electronic health record adoption in US hospitals: progress continues, but challenges persist. Health Affairs 2015;34(12):2174–80. Available from: http://content.healthaffairs.org/content/34/12/2174.abstract; https://doi.org/10.1377/hlthaff.2015.0992. PMid:26561387.

Charles D, Gabriel M and Furukawa MF. Adoption of electronic health record systems among U.S . Non-federal acute care hospitals: 2008–2013 [Internet]. 2014. Available from: http://www.healthit.gov/sites/default/files/oncdatabrief16.pdf. Accessed 20 November 2015.

The Office of the National Coordinator for Health Information Technology (ONC). Office of the Secretary USD of H and HS. Report to Congress: Update on Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information [Internet]. Vol. 3001. 2014. Available from: http://www.healthit.gov/sites/default/files/rtc_adoption_and_exchange9302014.pdf. Accessed 20 November 2015.

Strauss AL and Corbin JM. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications, 1998.

Chan J, Shojania KG, Easty AC and Etchells EE. Does user-centred design affect the efficiency, usability and safety of CPOE order sets? Journal of the American Medical Informatics Association 2011;18(3):276–81. Available from: https://academic.oup.com/jamia/article-lookup/doi/10.1136/amiajnl-2010-000026; https://doi.org/10.1136/amiajnl-2010-000026. PMid:21486886; PMCid:PMC3078654.

Lambooij MS and Koster F. How organizational escalation prevention potential affects success of implementation of innovations: electronic medical records in hospitals. Implementation Science 2015;11(1):75. Available from: http://implementationscience.biomedcentral.com/articles/10.1186/s13012-016-0435-1; https://doi.org/10.1186/s13012-016-0435-1. PMid:27206920; PMCid:PMC4875635.

Khajouei R and Jaspers MWM. The impact of CPOE medication systems’ design aspects on usability, workflow and medication orders a systematic review. Methods of Information in Medicine 2010;49:3–19. PMid:19582333.

Chan J, Shojania KG, Easty AC and Etchells EE.

Usability evaluation of order sets in a computerised provider order entry system. BMJ Quality & Safety 2011;20(11):932–40. Available from: http://qualitysafety.bmj.com/lookup/doi/10.1136/bmjqs.2010.050021; https://doi.org/10.1136/bmjqs.2010.050021. PMid:21807652.

Agha L. The effects of health information technology on the costs and quality of medical care. Journal of Health Economics 2014;34:19–30. Available from: http://www.sciencedirect.com/science/article/pii/S0167629613001720. Accessed 20 November 2015.

Hahn K, Ohman-Strickland P, Cohen D, Piasecki A, Crosson J, Clark E, et al. Electronic medical records are not associated with improved documentation in community primary care practices. American Journal of Medical Quality 2011;26(4):272–7. Available from: https://doi.org/10.1177/1062860610392365. PMid:21266596; PMCid:PMC3137715.

Huntington MK and Shafer CW. EHR implementation adversely affects performance on process quality measures in a community health center. American Journal of Medical Quality 2010;25(5):404–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20833986. Accessed 26 July 2014.

Zhou L, Soran CS, Jenter CA, Volk LA, Orav EJ, Bates DW, et al. The relationship between electronic health record use and quality of care over time. Journal of the American Medical Informatics Association 2009;16(4):457–64. Available from: http://jamia.oxfordjournals.org/content/16/4/457.abstract; https://doi.org/10.1197/jamia.M3128. PMid:19390094; PMCid:PMC2705247.

Price M, Singer A and Kim J. Adopting electronic medical records: are they just electronic paper records? Canadian Family Physician 2013;59(7):E322. PMid:23851560; PMCid:PMC3710063.

Liang LL, Berwick DM and Permanente K. Connected for Health: Using Electronic Health Records to Transform Care Delivery. San Francisco, CA: Jossey-Bass, 2010.

Hadji B, Martin G, Dupuis I, Campoy E and Degoulet P. 14 Years longitudinal evaluation of clinical information systems acceptance: the HEGP case. International Journal of Medical Informatics 2016;86:20–9.

Rogers EM and Singhal A. Diffusion of innovations. In: Salwen M, Stacks D (Eds), An Integrated Approach to Communication Theory and Research, 5th edition. Mahwah, NJ: LEA, 2003, pp. 409–19.

Moore GC and Benbasat I. Development of an instrument to measure the perceptions of adopting an information technology innovation. Information Systems Research 1991;2(3):192–222. Available from: https://doi.org/10.1287/isre.2.3.192.

Cooley TW, May D, Alwan M and Sue C. Implementation of computerized prescriber order entry in four academic medical centers. American Journal of Health-System Pharmacy 2012;69:2166–73. Available from: https://doi.org/10.2146/ajhp120108. PMid:23230041.

Boonstra A, Versluis A and Vos JFJ. Implementing electronic health records in hospitals: a systematic literature review. BMC Health Services Research 2014;14(1):370. Available from: http://www.biomedcentral.com/1472-6963/14/370; https://doi.org/10.1186/1472-6963-14-370. PMid:25190184; PMCid:PMC4162964.

Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW and Kaushal R. Overcoming barriers to adopting and implementing computerized physician order entry systems in US hospitals. Health Affairs 2004;23:184–90. Available from: https://doi.org/10.1377/hlthaff.23.4.184.

Gellert GA, Hill V, Bruner K, Maciaz G, Saucedo L, Catzoela L, et al. Successful implementation of clinical information technology: seven key lessons from CPOE. Applied Clinical Informatics 2015;6(4):698–715. Available from: https://doi.org/10.4338/ACI-2015-06-SOA-0067. PMid:26767065; PMCid:PMC4704039.

Ovretveit J, Scott T, Rundall TG, Shortell SM and Brommels M. Implementation of electronic medical records in hospitals: two case studies. Health Policy 2007;84(2–3):181–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17624470; https://doi.org/10.1016/j.healthpol.2007.05.013. PMid:17624470.

Ash JS, Stavri PZ, Dykstra R and Fournier L. Implementing computerized physician order entry: the importance of special people. International Journal of Medical Informatics 2003;69(2–3):235. Available from: https://doi.org/10.1016/S1386-5056(02)00107-7.

Ash JS, Stavri PZ and Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. Journal of the American Medical Informatics Association 2003;10: 229–34. Available from: https://doi.org/10.1197/jamia.M1204.

McGinn CA, Grenier S, Duplantie J, Shaw N, Sicotte C, Mathieu L, et al. Comparison of use groups perspectives of barriers and facilitator to implementing EHR—a systematic review. BMC Medicine 2011;9:46. Available from: https://doi.org/10.1186/1741-7015-9-46.

Sengstack PP and Gugerty B. CPOE systems: success factors and implementation issues. Journal of Healthcare Information Management 2004;18(1):36–45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14971078. PMid:14971078.

Weir C, Lincoln M, Roscoe D, Turner C and Moreshead G. Dimensions associated with successful implementation of a hospital based integrated order entry system. Proceedings the Annual Symposium on Computer Application [sic] in Medical Care 1994;653–7. PMid:7950009; PMCid:PMC2247902.

Safdari R, Ghazisaeidi M and Jebraeily M. Electronic health records: critical success factors in implementation. Acta Informatica Medica 2015;23(2):102–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26005276%5Cn; http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4430004; https://doi.org/10.5455/aim.2015.23.102-104. PMid:26005276; PMCid:PMC4430004.

Scott JT, Rundall TG, Vogt TM and Hsu J. Kaiser Permanente’s experience of implementing an electronic medical record: a qualitative study. BMJ 2005;331:1313–6. Available from: https://doi.org/10.1136/bmj.38638.497477.68.

Blavin F, Ramos C, Shah A and Devers K. Lessons from the literature on electronic health record implementation: a study funded by the Office of the National Coordinator for Health Information Technology of the U.S. Department of Health and Human Services [Internet]. 2013. Available from: http://www.healthit.gov/sites/default/files/hit_lessons_learned_lit_review_final_08-01-2013.pdf. Accessed 20 November 2015.

American Medical Association. Improving care: priorities to improve electronic health record usability [Internet]. 2014. Available from: https://download.ama-assn.org/resources/doc/ps2/x-pub/ehr-priorities.pdf. Accessed 6 October 2014.

Friedberg MW, Chen PG, Van Busum KR, Aunon FM, Pham C, Caloyeras JP, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy [Internet]. Santa Monica, CA: RAND Corporation, 2013. Available from: http://www.rand.org/pubs/research_reports/RR439.html.

Koopman RJ, Steege LMB, Moore JL, Clarke MA, Canfield SM, Kim MS, et al. Physician information needs and electronic health records (EHRs): time to reengineer the clinic note. The Journal of the American Board of Family Medicine 2015;28(3):316. Available from: https://doi.org/10.3122/jabfm.2015.03.140244. PMid:25957364.

Bonner LM, Simons CE, Parker LE, Yano EM and Kirchner JE. “To take care of the patients”: qualitative analysis of Veterans Health Administration personnel experiences with a clinical informatics system. Implementation Science 2010;5:63. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2931450/; https://doi.org/10.1186/1748-5908-5-63. PMid:20727182; PMCid:PMC2931450.

Jamoom EW, Patel V, Furukawa MF and King J. EHR adopters vs. non-adopters: impacts of, barriers to, and federal initiatives for EHR adoption. Healthcare 2014;2(1):33–9. Available from: http://www.sciencedirect.com/science/article/pii/S2213076413000845. Accessed 12 December 2015.

DOI: http://dx.doi.org/10.14236/jhi.v25i2.1011


  • There are currently no refbacks.

This is an open access journal, which means that all content is freely available without charge to the user or their institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal starting from Volume 21 without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open accessFor permission regarding papers published in previous volumes, please contact us.

Privacy statement: The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

Online ISSN 2058-4563 - Print ISSN 2058-4555. Published by BCS, The Chartered Institute for IT