A nearly two-year study of health care organizations shows why implementation of new technology often does not lead to true adoption. Interviews and surveys of health care leaders, conducted by The Breakaway Group, reveal the barriers that impede electronic health record adoption. They also provide insight into how to prepare hospital leaders for installing the EHR, how to develop role-specific simulator training programs, how to measure and monitor key indicators of adoption, and how to use metrics and online support communities to sustain EHR use.

Implementation vs. Adoption

Several themes have emerged from our research on medical groups and hospitals. One is an organizational focus on EHR implementation rather than adoption. While implementation is an early moment in the life of the EHR (go live), adoption is a process that lasts for the lifetime of the EHR (sustained knowledge and confidence over years).

Organizations need to move from an implementation focus to an adoption focus, but that requires a significant overhaul in how we think, lead and behave. A good indicator of adoption is when everyone is using the EHR according to the organizational policies, procedures and best practices. Only through adoption can the organization accomplish its desired patient care and financial outcomes.

Prepare and Engage Hospital Leaders

Engaged leaders who develop a strategy for long-term adoption and a governance structure to support that strategy provide the foundation for a sustainable EHR. Top managers must be committed to the EHR and consistently communicate its value to patients, providers and the organization. An effective governance structure includes such stakeholder groups as nursing, unit/clinic management, health information management and compliance.

It is particularly important to engage physician leaders, because physicians are critical to the success of EHR adoption. Physicians bring patients to the organization and personally deliver or direct patient care and, thus, are major drivers of the organization's expenditures. They have considerable informal power derived from their expertise and can either become strong advocates or quietly undermine EHR adoption efforts.

It is especially effective to institute a physician advisory committee with broad specialty representation, a charter delineating responsibilities, and a value statement for physician use of the EHR that is supported by top leaders. Physician champions and physician superusers engage other physicians.

Develop Role-Specific Simulator Learning

Traditional training methods are slow, expensive and generally ineffective. Classroom instruction is a passive learning experience that takes learners away from work for hours or days and often presents more material than needed as well as inaccurate, unclear information.

We suggest designing simulators focused on specific user knowledge. Simulators put clinicians inside real clinical scenarios to practice what they have learned, be tested through trial and error, and receive feedback on their performance.

Simulators have several advantages. They are available 24/7 via the Internet, something busy clinicians appreciate. The organization can present a customized curriculum that teaches by job role based on required proficiency levels for each role. Those who learn experientially are able to recall information more easily because they have practiced the specific tasks. Finally, a curriculum focused on user knowledge and confidence in workflow produces proficient users.

Measure and Monitor Key Indicators of Adoption

Organizations must prove meaningful use of an EHR to earn stimulus monies under the HITECH Act. The ultimate goal is to achieve improved clinical outcomes. Simply implementing or installing an EHR will not lead to improved health care outcomes or even stimulus monies. Adoption is merely the prerequisite for meaningful use, and organizations that achieve adoption should fulfill its intention: improved clinical outcomes.

Our research shows that few organizations are measuring adoption; they have only subjective assessments of whether clinicians actually are using the EHR. They cannot establish plans for improvement or measure progress. Without metrics, we lose the opportunity to identify gaps in adoption, which ultimately limits our ability to achieve improved clinical and financial outcomes.

The most challenging and valuable process is measuring performance metrics. These are the clinical and financial outcomes that drive the organization to purchase an EHR. The first step is to identify key performance metrics—often a daunting task because organizations must customize measurements to represent their specific desired outcomes. Examples may include: adherence to clinical guidelines, decrease in adverse drug events, decreased costs in medical records, and changes in complication and mortality rates and lengths of stay. The meaningful-use criteria also may serve as performance metrics.

We have observed organizations at various stages of EHR adoption, each with an opportunity to improve on key performance metrics. Those that measure performance and maintain the tenacity to seek continuous improvement are rewarded with a stellar reputation, loyal employees and clinical and financial success.

Develop an Online Community

Adoption is never static. Turnover, staff growth, workflow changes, application updates, and human factors of individual learning and retention all have an impact. The goal is to create an effective, sustainability plan. This requires resources, time and money, and is most successful when it is included in initial EHR budgeting and planning stages.

An effective plan first establishes how the organization will support users' ongoing needs for the life of the application. We have addressed this need by establishing a customized, easy-to-access, relevant, and meaningful Web-based community. It has a library with important reference documents and materials, an education center containing all task-based simulators, and an auditorium containing such valuable resources, tools and activities as videos, virtual meetings and archived events.

An effective plan also establishes how and when to collect metrics to assess user adoption and performance. Metrics are the differentiating factor between a highly effective sustainability plan and a mediocre one. User knowledge and confidence metrics are a barometer for levels of proficiency, providing the earliest indication of adoption. Ultimately, performance metrics are powerful indicators of whether end users are improving, maintaining or regressing in their adoption of the system. If we get an early warning that proficiency is slipping, we can react quickly to address the problem.

Adoption of an EHR is an enormous undertaking for any health care organization. With committed leaders, a customized curriculum, task-based simulators, continuous measurement of performance metrics, a sustainability plan and a Web-based library of learning resources, an organization can realize successful EHR adoption and positive clinical and financial outcomes.

Jeffrey R. Woodside, M.D., is the chief medical officer at The Breakaway Group, a health care information technology consulting firm based in Denver. Heather Haugen, Ph.D., is the corporate vice president of research for The Breakaway Group. They are the authors of Beyond Implementation: A Prescription for Lasting EMR Adoption (Denver: Magnusson Skor Publishing).

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.