The main findings of our systematic review suggest that 10 implementation factors are relevant to all user groups, and that among these factors design and technical concerns, cost issues, privacy and security concerns, lack of time and workload are among the most-cited. Systematic reviews by members of our team [31], Boonstra and Broekhuis [94] and Castillo et al. [95] support these findings. Their results confirm that financial, time-related, and technical barriers are the most-cited barriers to EHR acceptance and adoption. As Boonstra and Broekhuis also point out, these “primary” barriers are related to pressing first-hand problems related to EHR use, and that secondary factors related to social, psychological, and change processes may be less-mentioned in the literature. Our study highlights many individual, human, and organizational environment factors, such as motivation to use EHR and issues related to patient and health professional interaction, as well as many primary barriers, such as ease of use and productivity, that may need to be addressed simultaneously to encourage optimal EHR implementation.
This systematic review aimed to uncover not only similarities but also differences among user groups. Overall, studies involving physicians and health professionals provided data on the widest variety of factors. As opposed to the other user groups, studies related to patients cited few factors in the Organization category owing to the fact that patients are generally not privy to organizational processes. While accuracy of information contained within the EHR was one of the most-cited factors for patients [66, 68, 72, 79, 84, 89], accuracy was only mentioned in one other study, pertaining to managers [63]. Moreover, patients were the only user group to identify facilitating factors in a larger proportion than barriers and to consider autonomy, that is health empowerment and improved health self-management, as a positive EHR implementation factor [38, 72, 79].
Results from included studies on physicians, health professionals, and managers indicate the importance of eight organizational factors: practice size, change in tasks, human resources regarding IT support, training, management, relationship between administration and health professionals, choice of the EHR system, and interorganizational relations as influencing EHR implementation. These factors highlight the particular challenges these user groups face in their work environments. In studies where adequate technological support and training was provided, these factors tended to be perceived as facilitators, while studies which reported inadequate or no IT support or training tended to conclude that these factors were barriers to EHR implementation. Similarly, the managerial approach can be key to EHR implementation: forcefully implementing EHR contributed to failure while adopting a bottom-up approach fostered enthusiasm, dedication, and commitment from individuals, thus contributing to successful implementation [63]. Improving change management processes is a promising solution to overcoming these barriers since adequate change management can mediate other identified barriers [94].
User groups could also perceive the same factor differently. For instance, studies related to physicians, health professionals, and managers differently interpreted management involvement. Physician studies reported that a barrier to EHR implementation was the perception that the EHR system acted as a control mechanism allowing management to infringe on physicians’ professional autonomy [91, 93]. Studies on health professionals, however, tended to consider poor organization management practices as barriers to EHR implementation, such as a top-down leadership approach [50, 64], poor timing [36], and providing inadequate resources to support implementation [37, 90]. This same user group positively perceived reflexive management approaches [37, 50], prioritization and driving by the management team [51], and voluntariness [85] as facilitators. One study involving managers reported poor management techniques as a barrier that exacerbated implementation challenges and fostered passive resistance to EHR implementation [61].
Our study also raises a little-studied issue in that physicians may perceive their professional autonomy to be threatened or harbored by EHR implementation. Professional autonomy may generally be defined as ‘professionals’ having control over the conditions, processes, procedures, or content of their work according to their own collective and, ultimately, individual judgment in the application of their profession’s body of knowledge and expertise professional privacy’ [96]. Our systematic review found studies expressing concern about EHR systems infringing on physicians’ personal and professional privacy [83] and acting as management control mechanisms [91, 93]. This finding echoes innovative research by Walter and Lopez [96] pointing out that physicians’ perceived threat to professional autonomy has a significant negative impact on both perceived usefulness and intention to use an information technology. However, another study reported that general practitioners believe that: ‘contemporary health care requires a radical change in how confidentiality and privacy are defined (from a property of the individual doctor-patient relationship, mediated by the human qualities of the doctor, to a property of the system as a whole, mediated by technical and operational security measures)’ [37]. This issue should be explored in further research, particularly in the Canadian context.
A lack of uniform EHR standards, at local, regional, or national levels, was a clearly stated barrier in studies pertaining to physicians and managers [47, 57, 59, 63, 69]. Lack of standardization may contribute to physicians’ and managers’ disorientation when choosing an EHR system. Studies show that they were often inexperienced [35] and had difficulty selecting among many potential systems [92], which in some cases led to an inability to find an appropriate system or the implementation of an ill-suited system [47, 61, 62]. Certain studies also highlighted users’ lack of confidence in EHR vendors, such as fears that vendors may provide inadequate support [35] or go out of business [92]. Gans et al. [62] suggested that actions are needed to make the EHR decision process easier for practices, such as certification for EHR vendors and educational programs on how to select and implement an EHR system.
This systematic review adds to the current evidence that individual, human, and organizational barriers remain challenges that must be addressed in an innovative manner, according to the particular needs of each implementation project and each user group. Active participation of end-users in EHR implementation is a promising strategy since it allows decision-makers to consider users’ perspectives, gain their support, and adapt the technology to users’ needs [97].
Understanding the facilitators to EHR implementation is also key to successful implementation. Our study highlights two factors, perceived usefulness and motivation to use EHRs, as chief facilitators to EHR implementation. These two factors are closely related and should be considered when implementing EHRs since a positive perception of its usefulness increases users’ motivation to use it [63].
