title: Sustaining "meaningful use" of health information technology in low-resource practices.
abstract: OBJECTIVE
  The implementation of electronic health records (EHRs) has been extensively studied, but their maintenance once implemented has not. The Regional Extension Center (REC) program provides implementation assistance to priority practices-those with limited financial, technical, and organizational resources-but the assistance is time limited. Our objective was to identify potential barriers to maintenance of meaningful use of EHRs in priority primary care practices using a qualitative observational study for federally qualified health centers (FQHCs) and priority practices in Michigan.
  
  
  METHODS
  We conducted cognitive task analysis (CTA) interviews and direct observations of health information technology implementation in FQHCs. In addition, we conducted semistructured interviews with implementation specialists serving priority practices to detect emergent themes relevant to maintenance.
  
  
  RESULTS
  Maintaining EHR technology will require ongoing expert technical support indefinitely beyond implementation to address upgrades and security needs. Maintaining meaningful use for quality improvement will require ongoing support for leadership and change management. Priority practices not associated with larger systems lack access to the necessary technical expertise, financial resources, and leverage with vendors to continue alone. Rural priority practices are particularly challenged, because expertise is often not available locally.
  
  
  CONCLUSIONS
  Priority practices, especially in rural areas, are at high risk for falling on the wrong side of a "digital divide" as payers and regulators enact increasing expectations for EHR use and information management. For those without affiliation to maintain the necessary expert staff, ongoing support will be needed for those practices to remain viable.
authors.affiliation: Department of Family Medicine, University of Alberta, Alberta, Canada lagreen@ualberta.ca.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Green
authors.affiliation: Health Policy, Management, and Behavior, The University at Albany - SUNY, New York, New York.
authors.forename: Georges
authors.initials: G
authors.lastname: Potworowski
authors.affiliation: Altarum Institute, Ann Arbor, Michigan.
authors.forename: Anya
authors.initials: A
authors.lastname: Day
authors.affiliation: Altarum Institute, Ann Arbor, Michigan.
authors.forename: Rachelle
authors.initials: R
authors.lastname: May-Gentile
authors.affiliation: Altarum Institute, Ann Arbor, Michigan.
authors.forename: Danielle
authors.initials: D
authors.lastname: Vibbert
authors.affiliation: Altarum Institute, Ann Arbor, Michigan.
authors.forename: Bruce
authors.initials: B
authors.lastname: Maki
authors.affiliation: Altarum Institute, Ann Arbor, Michigan.
authors.forename: Leslie
authors.initials: L
authors.lastname: Kiesel
mesh_terms: D057286:Electronic Health Records; D006282:Health Personnel; D006295:Health Resources; D006801:Humans; D062527:Meaningful Use; D008490:Medical Informatics / Q000458:organization & administration*; D008824:Michigan; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D019035:Rural Health Services / Q000458:organization & administration*
keywords: American Recovery and Reinvestment Act; electronic health records; health information technology; meaningful use; primary health care; regional extension centers; rural health services; safety-net providers