title: CAH to CAH: EHR implementation advice to critical access hospitals from peer experts and other key informants.
abstract: The US government allocated $30 billion to implement electronic health records (EHRs) in hospitals and provider practices through policy addressing Meaningful Use (MU). Most small, rural hospitals, particularly those designated as Critical Access Hospitals (CAHs), comprising nearly a quarter of US hospitals, had not implemented EHRs before. Little is known about implementation in this setting. Socio-technical factors differ between larger hospitals and CAHs, which continue to lag behind other hospitals in EHR adoption.
  
  
  OBJECTIVE
  The main objective is to provide EHR implementation advice for CAHs from a spectrum of experts with an emphasis on recommendations from their peers at CAHs that have undertaken the process. The secondary objective is to begin to identify implementation process differences at CAHs v. larger hospitals.
  
  
  METHODS
  We interviewed 41 experts, including 16 CAH staff members from EHR teams at 10 CAHs that recently implemented EHRs. We qualitatively analyzed the interviews to ascertain themes and implementation recommendations.
  
  
  RESULTS
  Nineteen themes emerged. Under each theme, comments by experts provide in-depth advice on all implementation stages including ongoing optimization and use. We present comments for three top themes as ranked by number of CAH peer experts commenting - EHR System Selection, EHR Team, and Preparatory Work - and for two others, Outside Partners/Resources and Clinical Decision Support (CDS)/Knowledge Management (KM). Comments for remaining themes are included in tables.
  
  
  CONCLUSIONS
  CAH experts rank the themes differently from all experts, a likely indication of the differences between hospitals. Comments for each theme indicate the specific difficulties CAHs encountered. CAH staffs have little or no EHR experience before implementation. A factor across themes is insufficient system and process knowledge, compounded by compressed implementation schedules. Increased, proactive self-education, via available outside partners and information resources, will mitigate difficulties and aid CAHs in meeting increased CDS requirements in MU Stages 2 and 3.
authors.affiliation: MU Informatics Institute, University of Missouri , Columbia, Missouri.
authors.forename: C K
authors.initials: CK
authors.lastname: Craven
authors.affiliation: MU Informatics Institute, University of Missouri , Columbia, Missouri.
authors.forename: M C
authors.initials: MC
authors.lastname: Sievert
authors.forename: L L
authors.initials: LL
authors.lastname: Hicks
authors.forename: G L
authors.initials: GL
authors.lastname: Alexander
authors.forename: L B
authors.initials: LB
authors.lastname: Hearne
authors.affiliation: Department of Biostatistics & Epidemiology, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.
authors.forename: J H
authors.initials: JH
authors.lastname: Holmes
mesh_terms: D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D005104:Expert Testimony; D006284:Health Plan Implementation; D006297:Health Services Accessibility; D006780:Hospitals, Rural; D006801:Humans; D010379:Peer Group
keywords: Electronic health records; critical access hospitals; medical informatics; qualitative research; rural hospitals
references.citation: J Am Med Inform Assoc. 2009 May-Jun;16(3):291-9
references.pmid: 19261935
references.citation: Health Aff (Millwood). 2004 Jul-Aug;23(4):184-90
references.pmid: 15318579
references.citation: Am J Manag Care. 2013 Jul 01;19(7):e273-84
references.pmid: 23919447
references.citation: J Am Med Inform Assoc. 2012 Nov-Dec;19(6):980-7
references.pmid: 22707744
references.citation: Int J Med Inform. 2003 Mar;69(2-3):235-50
references.pmid: 12810127
references.citation: Harv Bus Rev. 2002 Jul;80(7):107-11, 126
references.pmid: 12140850
references.citation: Methods Inf Med. 2006;45(1):125-36
references.pmid: 16482383
references.citation: Health Aff (Millwood). 2013 Aug;32(8):1478-85
references.pmid: 23840052
references.citation: Stud Health Technol Inform. 2013;192:608-12
references.pmid: 23920628
references.citation: J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34
references.pmid: 12626376