Physician resistance as a barrier to implement clinical information systems
Implementation of electronic medical record (EHRs) that contains computer physician order entry (CPOE) backed with Clinical Decision Support System (CDSS) is a vital component of strategies to prevent medication errors with a significant relative risk reduction of 13% to 99% . A growing body of evidence calls for its widespread implementation (2). However, implementation of CPOE is slower and more problematic than anticipated and often poorly integrated, inducing new errors and interfering with users’ usual workflow (3, 4). By the end of the first quarter of 2010, only 15.2% of US hospitals have implemented CPOE systems (5). Both qualitative and quantitative studies cited the high cost and physician resistance are the top barriers to implement clinical information systems (6, 7). While recent financial incentives and penalties through Medicare and Medicaid toward meaningful use of EHRs are promising solution for the first barrier (8), we need a comprehensive act toward the second barrier, resistance.
Resistance behavior can be defined as a force that acts to stop the progress of new ideas and changes (9, 10). This behavior can take broad spectrum of manifestations varying from inaction to destructive actions. A four-level taxonomy, which was proposed by Coestsee (11-13), classified resistance behaviors to apathy, passive resistance, active resistance and aggressive resistance.
- Apathy: inaction, distance, and lack of interest.
- Passive resistances: delay tactics, excuses, persistence of former behavior, and withdrawal.
- Active resistances: voicing opposite points of view, asking others to intervene or forming coalitions
- Aggressive resistance: infighting, making threats, strikes, boycotts, or sabotage (13).
Where there is a change, resistance should be expected. Our aim is not to eradicate it, since we cannot, rather to alleviate it. Many strategies, which were put forward in the literature, have been applied successfully to alleviate or overcome physician resistance to adopt clinical information systems. I classified those solutions as administration, physician, nurse, patient, vendor, system and setting factors. This classification is not inclusive neither complete separative.
Physicians usually draw a picture of expectorations in their minds about new systems during the pre-implementation phase. If expected consequences are not met, resistance behaviors will result (13). Therefore, evolving physicians in system design is critical to success of implementation (14, 15). Moreover, financial reimbursement for physicians participated in system design is a further benefit. Their contribution should not be mere virtual rather must demonstrate quick response and follow-through. A successful story of CPOE implementation project from Sarasota Memorial Health System, Sarasota, FL, supported the notation of Clinician-led project team with information technology professionals (IT) support (14). Classically, the reverse is pursued, where IT professionals lead the project and has supporting clinicians. Identifying physician leaders and champions can overcome other staff resistance. These leaders can advocate for the new system implementation and deal with their colleagues concerns in the scene. Also, they would relay users’ concerns to the implementation team and the vendors (7).
With the implementation of new systems that interfere with clinical workflow, a rise in workload and concomitant drop of productivity is expected. Typically, six months is needed to gradually reach the pre-implantation production. To avoid resistance, financial and logistic compensation is the organization responsibility during this critical period.
Physician duty is to eliminate patients’ suffering and avoid any harm to them. Hence, prioritizing of patient safety should be above other concerns, such as workload and pecuniary consecrations. Keeping that in mind with the established evidence of correlation between CPOE implementation and reduction of medical errors (1, 16) should lead physicians to accept CPOE implantation. That can be achieved by well-advised educational programs in undergraduate, graduate and continuous medical education levels.
Resident physicians, who are usually rotate from an institute/ department to another, are supposed to be the main users of CPOE. Nurses should provide continuous assistance to physicians new to learning the new system to help change ordering patterns and play down resistance (14). CPOE system factors A good CPOE system is supposed to meet users’ needs and expectations. From the interface view, users prefer easy, web-based and colored interface the CPOE system (17). Enabling an alternative way to execute physician orders, esp. in case of emergencies, is a major concern for physicians.
Affording sufficient portals, computers and printers in the setting is an essential requirement before the implementation of the new system. Additionally, meet the pint-of-care requirement of mobile devices such as laptops on trolleys, bedside laptops and/or supporting personal digital assistant (PDA) devices access to the system will increase the physician acceptance. One of the main facilitators of adoption of clinical information systems is the availability of formative training and round-the-clock technical support (18).
It is advantageous to choosing vendors that are committed to address physicians´ workflow concerns through customization and improvement of the CPOE product (6, 7).
Patient satisfaction directly influence physician acceptance. Since the use of computer devices may demand much of the physician's attention and could disturb the communication with the patient (19, 20), minimal-attention user interface design is advisable. Patients and clinicians differ substantially on the regard of their preferred means of communication (21). Therefore, Patient point of view should be involved in the planning and implementing of clinical information systems. Patient survey and/or patient representatives can achieve that aspiration. Announcing the implementation of CPOE with accompanying clarification of benefits related to patients’ safety and privacy will eliminate patients’ annoyance from potential stumbles in the implementation phase, and subsequently reduce their physicians’ resistance.
In summary, physician resistance toward implementation of clinical information systems is a major barrier. Strategies acknowledged under various categories to overwhelm this barrier provide hope to organizations that are eager to take on this adventure. Decision makers carry the chief responsibility to put in advance clear rules to facilitate physicians’ participation in the implementation process to eliminate their later on opposition.
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Submitted by Amr Jamal, MD, SBFM, ABFM, MRCGP[Int.]