Review Of Related Literature

BSN 3Y3-6 GRP. A Carpio, Angelo Cabral, Antonette Castillo, Kathleene Clemente, Ivy Espiritu, Lisette Estores, Judith Maiztegui, Jhomar Semil, Cristine

Carpio, Angelo 70 New Doctors Trained on Telemedicine Before Barrio Work Tagaytay City, Philippines- National Telehealth Center (NTHC) of the University of the Philippines Manila is preparing 70 new DOH Doctors to the Barrios (DTTBs) in using telemedicine applications in an effort to support their practice in doctorless communities in the countryside. The 29th batch of DTTBs under the Doctors to the Barrios Program of the Department of Health (DOH) began their training last October 17 at the Development Academy of the Philippines Campus. They are officially enrolled in NTHCs Certificate Course in eHealth and Telemedicine which is a part of the 30-million National Telehealth Service Program (NTSP) recently forged by the NTHC with the DOH. NTSP aims to help DTTBs handle patients in their assigned communities; including those that need specialty care. Currently, there are already 109 doctors from Batanes to Zamboanga enrolled in the NTSP. DTTBs are being taught how to do telereferrals to refer difficult to handle cases in 5th to 6thclass municipalities of the country. 26 of them will be deployed in the Mindanao while some will be assigned in Geographically Isolated and Disadvantaged Areas. Due to the absence of doctors in rural communities, most patients have to travel long hours in order to seek medical attention from clinical specialists in provincial or city centers. According to President Benigno S. Aquino III, as reported by DOH Secretary of Health Enrique T. Ona in his speech last March, 30 percent of Filipinos die without seeing a health professional. Telemedicine offers some relief to the countrys health challenges by connecting health workers in poor remote rural communities with specialists in the Philippine General Hospital. With the implementation of the 5-year partnership of DOH and UP under the National Telehealth Service Program (NTSP), local health professionals from 606 poorest municipalities and regional centers will be connected to clinical specialists via telemedicine. Telemedicine has to be practiced professionally, grounded on a strong ethicallegal base; hence the need to train health professionals is a core component of the NTSP, Dr. Portia Fernandez-Marcelo, NTHC director said. Telemedicine, under the NTSP is free of charge to the patients since this is subsidized by the DOH and the UP. While ICT advancements are beginning to be used in health care in the Philippines, the public is warned against those who take advantage of the situation, she added. According to Dr. Marcelo, there were informal reports that some doctors in the rural areas, who are not

enrolled in the certificate course of NTSP, are charging 300 pesos for telemedicine of NTHC. The course consists of a two day-intensive hands-on training on the ethics and practice of telemedicine. On the first day, a series of discussions for the doctors Continuing Medical Education was held. This was followed by the hands-on training on mobile health technologies. The Certificate Course in eHealth and Telemedicine is a 6-month blended learning course with 2-day face-to-face learning activities, followed by field practice and mentoring, capped by another 1-day face-to-face seminar workshop. The UP Manila National Telehealth Center Established in June 1998, the University of the Philippines National Telehealth Center (UPM NTHC), has been collaborating with different sectors in the realm of information and communications technology (ICT) for health and development. The Center affirms its mandate of putting health in the hands of the people through available technologies by linking health care professionals of the Premier State University and the communities, especially the underserved. The Center works under the OneHealth banner, NTHCs three-point program that merges innovative applications in eLearning, eRecords, and eMedicine for health care and eHealth policy advocacy. UPM NTHC collaborates with like-minded institutions to harness support for better health care for all through technologies that are accessible, affordable, appropriate, and culturally acceptable for Filipinos. By banking on individuals capacities, the center believes that people can use information and communications technology for sound decision making contributing to better health outcomes. NTHC technologies are built in the strength of free and open source software.

http://nurseslabs.com/4814/70-new-doctors-trained-on-telemedicine-before-barrio-work/

Linking Primary Care Information Systems and Public Health Vertical Programs in the Philippines: An Open-source Experience Community-based primary care information systems are one of the building blocks for national health information systems. In the Philippines, after the devolution of health care to local governments, we observed health information

system islands connected to national vertical programs being implemented in devolved health units. These structures lead to a huge amount of information work in the transformation of health information at the community level. This paper describes work done to develop and implement the open-source Community Based Health Information Tracking System (CHITS) Project, which was implemented to address this information management problem and its outcomes. Several lessons learned from the field as well as software development strategies are highlighted in building community level information systems that link to national level health information systems.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560490/

Cabral, Antonette Transcending the delivery of healthcare for Filipinos through Electronic Health Records in Rural Health Units CHITS: The Open Source for Health Development Initiative In line with its mandate to increase access to health information andservices through information and communications technology, theUniversity of the Philippines Manila - National Telehealth Center(UPM-NThC) has developed the Community Health Information Tracking System or CHITS, a low cost computerization initiative for localhealth centers. CHITS was envisioned to automate the core processes inthe health center and contribute to effective and efficient delivery of services. (Content by:Herman D. Tolentino, M.D.Alvin B. Marcelo M.D.Alex I. Gavino, M.D.Noel A. Baez, R.N. CHITS Primer published on August 2010)
http://www.scribd.com/doc/64364804/UPM-NThC-Community-Health-Information-Tracking-SystemCHITS-Primer

QC recognizes UPs health info system as tool in disease tracking CHITS strengthens or even introduces skills in ICT use for health, deepens their appreciation for better quality data, strengthens their commitment in serving the public mostly the poor who seek care in their health centers. CHITS introduces the values of FOSS or free and open source software openness, sharing, accountability, giving back to the community.
http://nurseslabs.com/3781/qc-recognizes-up%E2%80%99s-health-info-system-as-tool-in-diseasetracking/

CHITS eyed as a tracking tool for Maternal and Neonatal HealthApr20 The Community Health Information Tracking System (CHITS), an electronic medical record system for rural health units, was presented during the technical working group workshop of the Joint Programme on Maternal and Neonatal Health (JPMNH) last April 19, 2011 at the Meralco Management & Leadership Development Center (MMLDC) in Antipolo.Basically we started CHITS based on FHSIS-generated reports. But we now see the possibilities of expanding its features to in tracking mothers and babies using indicators of the JPMNH, explains Dr. Marcelo.

We see the potential of using CHITS for system-generated patient information as well as inventory management system for the JPMNH, expresses Dr. Florence V. Tienzo, National Professional Officer of WHO.
http://one.telehealth.ph/beta/2011/04/20/chits-eyed-as-a-tracking-tool-for-maternal-and-neonatalhealth/

Castillo, Kathleene Problems measuring community health status at a local level: Papua New Guinea's health information system. The Papua New Guinea Department of Health monitors the performance of the health system using a computerised national health information system. This article draws on the recent evaluation of a national-wide donor-project community development initiative to highlight the problems of the lack of and disaggregated village health data. This data could be used to monitor health status, health worker performance and intervention impact. Healthier lifestyle and enhanced social and economic wellbeing were claimed by the community to be the result of the project intervention. The evaluation found village claims of post-project improved physical health, increased use of health services and reduced maternal and child mortality could not be substantiated statistically. Health-centre data failed to provide a complete and accurate assessment of community health status within the national health information system. This article highlights problems in evaluating community interventions or local service performance if reliable village-level data is absent. The health information system does not allow reporting of villages separately or the tracking of changes in health status over time according to identifiable villages. Assessing changes in physical health status is not possible without village-level baseline data to measure illness trends and improvements in health in identifiable villages. There is a need for policy changes to occur at national level to prevent loss of aid-post data from the system. Future planning for community health intervention strategies need to include disaggregated villagelevel baseline data against which to measure changes in community health status over time. http://www.ncbi.nlm.nih.gov/pubmed/21214300 CATCH/IT: a data warehouse to support comprehensive assessment for tracking community health A systematic methodology, Comprehensive Assessment for Tracking Community Health (CATCH), for analyzing the health status of communities has been under development at the University of South Florida since the early 1990s. CATCH draws 226 health status indicators from multiple data sources and uses an innovative comparative framework and weighted evaluation criteria to produce a rank-ordered list of community health problems. CATCH has been applied successfully in many Florida counties; focusing attention on high priority health issues and measuring the impact of health expenditures on community health status outcomes. Previously performed manually, we are

using information technology (IT) to automate the CATCH methodology with a full-scale data warehouse, user-friendly forms and reports, and extended analysis and data mining capabilities. The automated system, CATCH/IT, will reduce the time to prepare community health status reports from months to days. In this paper, we present the current status of the project, along with the principal research and development issues and future directions of the project.
http://www.ncbi.nlm.nih.gov/pubmed/9929220

Linking Primary Care Information Systems and Public Health Vertical Programs in the Philippines: An Open-source Experience Community-based primary care information systems are one of the building blocks for national health information systems. In the Philippines, after the devolution of health care to local governments, we observed health information system islands connected to national vertical programs being implemented in devolved health units. These structures lead to a huge amount of information work in the transformation of health information at the community level. This paper describes work done to develop and implement the open-source Community Based Health Information Tracking System (CHITS) Project, which was implemented to address this information management problem and its outcomes. Several lessons learned from the field as well as software development strategies are highlighted in building community level information systems that link to national level health information systems.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560490/

Clemente, Ivy CHITS eyed as a tracking tool for Maternal and Neonatal Health Pasay City Health District officer Dr. Marie Irene R. Sy highlighted the features and benefits of CHITS particularly targeting the maternal and neonatal health as manifested in the 7 years experience of Pasay City. CHITS has maternal and child health modules as well as an SMS (Short Message Service) appointment system for tracking mothers and babies for their health service schedule. Former UPM-NThC director and original CHITS proponent Dr. Alvin B. Marcelo was also present to answer the queries regarding CHITS during the open forum. Basically we started CHITS based on FHSIS-generated reports. But we now see the possibilities of expanding its features to in tracking mothers and babies using indicators of the JPMNH, explains Dr. Marcelo. We see the potential of using CHITS for system-generated patient information as well as inventory management system for the JPMNH, expresses Dr. Florence V. Tienzo, Health Specialist of The World Bank. The joint programme intends to increase equitable access to and utilization of reproductive health, and maternal and newborn information, goods and services in priority areas, and enhance effectiveness of national and subnational support to local planning, implementation, and monitoring of the DOHs Maternal, Newborn and Child Health and Nutrition strategy.
http://www.chits.ph/web/?p=72

Practice EMR, CHITS and Medhelp Today, we practiced how to use CHITS. For quite sometime now, we've incorporated CHITS in our every discussion of different programs related to Informatics. This day, we're actually going to utilize it, as well as EMR and an online personal health monitoring program which is, Medhelp. CHITS-we created a new patient and entered fabricated data. We finally experienced how to actually use CHITS. I discovered that if you set a follow up check up on a certain date, it will be highlighted when that specific day comes. It is actually cool. It will remind and notify the HCProviders of the patients who will be coming for followup check up on a specific day. EMR-Electonric Medical Record. I find it very similar to a paper-based

patient chart only more complex. It will be very useful especially here in the Philippines where public hospitals are always bombarded with lots of patients. It will definitely make a nurse's job lighter. I hope that EMR will be implemented here soon. It will be better for the patients as well as for the nurses and doctors. Patient records are also more secured if they are stored using the EMR. There will be lesser mistakes and the all time dilemma of new nurses-'CANNOT UNDERSTAND THE DOCTOR'S PENMANSHIP'.
http://www.medhelp.org/user_journals/show/196040/Practice-EMR--CHITS-and-Medhelp-May-20-2010

Sultan Kudarat participates in CHITS training The 3-day CHITS training included a Lakbay Aral tour of an actual CHITS installation in Malibay Health Center in Pasay City. The participants were able to witness the operational flow of CHITS in a health center. Dr. Armand Lee, physician-in-charge of Malibay was there to answer the queries from the Sultan Kudarat health workers. Pasay City Health Office and CHITS original stalwarts Dr. Marie Irene R. Sy and PHN Mr. Rosendo Pantino were also in attendance. Importance of health information system, quality data, ethics, and patient record security were mainly discussed during the training program. Basic CHITS patient registration and modules on the Department of Health (DOH) health programs such as General Consults, Expanded Program on Immunization (EPI), Maternal and Child Health (MCH), National Tuberculosis Control Program (NTP), Leprosy, Dental, Notifiable Diseases among others were also taught to the trainees. The attendees for the training include rural health physicians, chiefs of hospitals, and public health nurses from Sultan Kudarat Provincial Health Office, Provincial Hospital, DOH Representative and Center for Health Development (CHD) Region XII. They were mainly composed from the Inter Local Health Zone (ILHZ) collectively known as BITES (Bagumabayan, Isulan, Tacurong, Esperanza, and Senator Ninoy Aquino).
http://www.chits.ph/web/?p=75

Espiritu, Lisette Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries. The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap. The purpose of this review was to identify the current state of knowledge about health information systems adoption in primary care. The goal was to understand factors and influencers affecting implementation outcomes from previous health information systems implementations experiences. A comprehensive systematic literature review of peer reviewed and grey literature was undertaken to identify the current state of knowledge regarding the implementation of health information systems. A total of 6 databases, 27 journal websites, 20 websites from grey sources, 9 websites from medical colleges and professional associations as well as 22 government/commission websites were searched. The searches returned almost 3700 article titles. Eighty-six articles met our inclusion and exclusion criteria. Articles show that systems' graphical user interface design quality, feature functionality, project management, procurement and users' previous experience affect implementation outcomes. Implementers had concerns about factors such as privacy, patient safety, provider/patient relations, staff anxiety, time factors, quality of care, finances, efficiency, and liability. The review showed that implementers can insulate the project from such concerns by establishing strong leadership, using project management techniques, establishing standards and training their staff to ensure such risks do not compromise implementation success. The review revealed the concept of socio-technical factors, or "fit" factors, that complicate health information systems deployment. The socio-technical perspective considers how the technical features of a health information system interact with the social features of a health care work environment. The review showed that quality of care, patient safety and provider/patient relations were not, positively or negatively, affected by systems implementation. The fact that no articles were found reviewing the benefits or drawbacks of health information systems accruing to patients should be concern to adopters, payers and jurisdictions. No studies were found that compared how provider-patient interactions in interviews are effected when providers used electronic health information systems as opposed to the paper equivalent. Very little information was available about privacy and liability
http://www.ncbi.nlm.nih.gov/pubmed/18644745

Implementing electronic health records: Key factors in primary care Implementing electronic health records (EHRs) in primary health care is important, yet it poses many challenges. We use the term electronic health records throughout this paper to reflect the range of providers, including family physicians, nurses, nurse practitioners, chiropodists, and others, who use

EHRs. These records are more commonly referred to in the literature as electronic medical records. There is growing recognition of the role of EHRs in the provision of health care, particularly because they can enhance the quality of health care provided through decision-support functions, increase collaboration among members of care teams, and address health care providers need for information. Also, use of information technology systems has been linked to a decrease in medical errors. Using EHRs could improve patients health outcomes through enhanced disease management and increased levels of preventive care. Finally, some efficiency can be realized through eliminating routine tasks, such as pulling paper-based charts. Despite the benefits of EHRs, particularly in the areas of patient safety and improved quality of health care, adoption has been slow. Relatively few family physicians in Ontario and throughout Canada currently use EHRs in their practices. Research on the usefulness of EHRs in primary health care has focused on practitioners performance and system efficiencies; however, there is a need for further studies to examine the effect of computerization on patient and health care team outcomes.6 A lack of research describing specific, individual experiences of implementing information technology in health care has been noted.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377228/?tool=pubmed

Costs and Benefits of Health Information Technology A small body of literature supports a role for HIT in improving the quality of pediatric care. Insufficient data were available on the costs or cost-effectiveness of implementing such systems. The ability of Electronic Health Records (EHRs) to improve the quality of care in ambulatory care settings was demonstrated in a small series of studies conducted at four sites (three U.S. medical centers and one in the Netherlands). The studies demonstrated improvements in provider performance when clinical information management and decision support tools were made available within an EHR system, particularly when the EHRs had the capacity to store data with high fidelity, to make those data readily accessible, and to help translate them into context specific information that can empower providers in their work. Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs. However, the predicted time needed to break even varied from three to as many as 13 years. HIT has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient. Some organizations have already realized major gains through the implementation of multifunctional, interoperable HIT systems built around an EHR. However, widespread implementation of HIT has been limited by a lack of generalizable knowledge about what types of HIT and

implementation methods will improve care and manage costs for specific health organizations. The reporting of HIT development and implementation requires fuller descriptions of both the intervention and the organizational/economic environment in which it is implemented.
http://www.ahrq.gov/downloads/pub/evidence/pdf/hitsyscosts/hitsys.pdf

Estores, Judith Community Health Information Tracking System (CHITS) Injury control is a pressing problem in developing countries. Because injury affects the productive segments of society, it must be managed decisively. The most effective control method is prevention but this is premised on a good registry system. Data from this injury registry system will help policy-makers focus prevention programs on types of injuries that impact on the most number of people. One of those most severely affected are children (WHO: <=18 years). This subset is vulnerable due to inexperience and do not have ready access to health care. To be able to improve injury prevention programs for children, a good injury registry is needed Community-based data collection systems in resource-constrained societies have been difficult to implement. In this study, open-source tools from the Linux community combined with participative people-centric strategies will be employed to enable implementation of a child injury surveillance system by health workers. This project proposes a reporting system has three main components: a short messaging system for reporting child injuries, the training of village health workers on injury surveillance, and a web-based graphical presentation system of injury data for decision makers. It will be implemented in an urban poor village as pilot. SMS has been chosen because of its widespread penetration in the Philippines and its wireless capabilities. Currently there is no reported use of Short Messaging System for disease surveillance. The early detection of disease, which covers this study, is an emerging field in public health informatics.
http://www.apdip.net/projects/ictrnd/2003/L41-sms

The Wireless Access for Health project aims to streamline this reporting process by building on and strengthening the existing Community Health Information Tracking System (CHITS), an electronic medical-record system developed by the University of the Philippines Manila. CHITS improves patient care and access to public-health information by consolidating data captured during patient visits into reports for health-care workers in four health units in Tarlac. According to the project leaders, the initial results were positive at the health units in Gerona, Moncada, Paniqui and Victoria. The system has been

drastically improved, as CHITS now can instantly generate all 23 of the DOHs FHSIS reports, allowing for improved patient care and more efficient patient visits, as the time needed to search for records is reduced to just seconds. Good health is fundamental to our lives. The use of electronic health-record systems improves patient care and public health by making it easier for healthcare workers to both record and report patient information, said John Stefanac, vice president of Qualcomm and president of Qualcomm Southeast Asia and Pacific. Moreover, the program has also trained 40 midwives and nurses to use computers for the first time, and Tarlac State University has gained experience in CHITS software development. As a result, there was an increase in knowledge, experience and resources for the various levels of health-care decision-makers. One result of this initiative is awareness among our partners in local health offices and local government units of the importance of data quality, said Myra Emata- Stokes, chief of the US Agency for International Developments (USAID) program resources management. This initiative makes it easy for partners to realize that the natural next step to systematic health-information recording is data analysis and data utilization in places where these processes have not normally existed even at the level of the rural-health units, which are the most basic point of publichealth service. Also in a statement, Smart Communications chairman Manuel V. Pangilinan pointed out the project shows the vital role of telecommunications in upgrading the public-health system by making it more effective and efficient in serving people even in remote areas of the country. This project is made possible through the collaboration of public-private partners: agencies of the DOH, including the National Epidemiology Center, the Information Management Service and the Center for Health Development for Region 3, local government units in Tarlac, Qualcomms Wireless Reach initiative, RTI International, Smart Communications Inc., Tarlac State University, the University of the Philippines Manila-National Telehealth Center and USAID.
http://philippines.usaid.gov/newsroom/technology-benefits-rural-health-care

How ICT contributes to the organisational objectives: (1) It has created paper-less health centers operated by community health center staff (indigenous health workers public health nurses midwives etc.).(2)

It has integrated several vertical and previously disconnected health information systems of the Ministry of Health at the community level making data processing more efficient and processed health information readily available for local use (previously difficult to do)(3) It has empowered local health center staff to take charge of information management through capacity building(4) It has contributed to the improvement of quality of health information coming from the grassroots through capacity building and professionalized training programs implemented by the University of the Philippines The project has been fully implemented in the target communities since September 2004. Ongoing activities include software maintenance marketing grant-seeking partnership development with like-minded non-government organizations collaboration with the Department of Health and the Department of Science and Technology. We are exploring potential partnerships with University of Sydney (for AusAID funding) to further develop clinical record exchange cross-training and faculty exchange and deployment of multilingualization features and rural area testing and deployment.
http://www.stockholmchallenge.org/project/data/community-health-information-tracking-system

Maiztegui, Jhomar Health Information Technology and Physicians' Perceptions of Healthcare Quality Health information technology has become a multifunctional system and appears to have enhanced physicians perception of providing high-quality care. Physicians perceptions of medical care quality improved as the number of HIT types used increased. This study supports more extensive use of HIT in physician practices.
http://www.ncbi.nlm.nih.gov/pubmed/21504261

Hospital-community electronic medical record As medical treatment becomes more technically sophisticated, there is a growing need for transfer of information between care sites. However, only low rates of patients present a referral letter or discharge letter that includes relevant information. Therefore, Clalit identified the need for an integrated medical record system to facilitate access of physicians at different sites to the relevant medical information needed for providing high quality care. The integrated electronic medical record is designed to collect medical data in an automatic, on-line manner from seemingly incompatible data sources, which are decentralized. The data is brought together as information that is reliable and available for all care providers, at each site of care. The solution, developed and implemented by db motion, was based on the requirement to collect data from the existing systems without having to replace them, change their function or change the way they are utilized. In addition, the solution utilizes existing infrastructures for communication and data transfer such as the LAN and WAN networks or the Internet. The solution developed by db motion consists of an information highway between the data creators and consumers in the organization that enables an information consumer to request and receive specific patient information automatically and quickly, without the need to install any program at the end user's station (by using a standard Internet browser), and without making any changes in the existing work processes or in the organization's structure. The solution provides available, up-to-date relevant medical information to each site of care while maintaining the highest level of information security, because each physician can only access the information about his patients. In addition, the solution is capable of connecting the user to various databases needed for providing optimal care. The described solution is installed in most of Clalit Health Services' hospitals and in most districts (each district controls clinics, labs and institutes), and provides up-to-date information at the point of care.

http://www.hpm.org/de/Surveys/Brookdale_Institute_-__Israel/06/Hospitalcommunity_electronic_medical_record.html

Community Health Information Tracking System (CHITS) Since the devolution of the national health care system, it has been a challenge to consolidate data from each of the different reporting units into a cohesive and relevant whole. Reporting is still paper based, making it prone to error, destruction, and alteration. Consolidation of paper records is also time consuming, making the information derived from it less relevant to the national health system and to the communities who generate the data. In line with its mandate to increase access to health information and services through information and communications technology, the National Telehealth Center (NthC) engages with local government units and offers a solution in the form of the Community Health Information Tracking System (CHITS), a low cost computerization project for the barangay health center. CHITS is software for the village health center that combines the features of an electronic health record and clinic appointment system while also integrating modules for different national health programs. It is an extensible, modular system that leverages existing routine health information systems (vertical programs) in public health to serve as a starting point for implementing comprehensive information system integration. Through CHITS, communitybased health information is made available not only to public health agencies requiring community level information but also to the community itself that generates the information. It enables the community to use this information for local decision-making.
https://docs.google.com/View?id=dgscbt2w_352fqz2nk

Semil, Cristine Describing the influence of technologies on registered nurses' work Content analysis revealed that technologies enhanced nursing practice by improving direct care processes, patient outcomes, and work environments. Working with inefficient systems of technology delivery, use, and repair created challenges for nurses and physically unfriendly equipment increased the burden of nurses' work. Nurses bypassed problems rather than proactively solving them, occasionally leading to safety breeches. Technologies led to changing nurse role expectations and altered healthcare team dynamics.
http://www.ncbi.nlm.nih.gov/pubmed/18438162

Primary health care teams' experience of electronic medical record use after adoption Emergent from the data were five interwoven elements of team behavior when using the EMR. Consistent data entry was imperative to successful EMR utilization. The EMR software was utilized differently depending on the role of the team member. Team members continued to seek out a team champion/problem solver to help overcome obstacles. Communication was enhanced by using the common messaging system within the EMR. Finally, success with certain functions such as communication, champion enthusiasm, and recognition of the value of the EMR encouraged others to learn additional features and advanced the adoption process.
http://www.ncbi.nlm.nih.gov/pubmed/22002775

How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, preimplementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key

activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process. The EHR implementation experience depends on a variety of factors including the technology, training, leadership, the change management process, and the individual character of each ambulatory practice environment. Sound processes must support both technical and personnel-related organizational components. Additional research is needed to further refine recommendations for the small physician practice and the nuances of specific medical specialties.
http://www.ncbi.nlm.nih.gov/pubmed/19236705