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Physician resistance as a barrier to implement clinical information systems

By Dr.Mahboob Khan Phd

Background

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.

Introduction

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).

Solutions

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.

Administration factors

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, supported the notation of Clinician-led

project team with information technology professionals (IT) support (14). Classically, the reverse is pursued,

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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 factors

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.

Nurse factors

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.

Setting factors

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).

Vendor factors

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 factors

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.

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Conclusion

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.

1. Dr.Mahboob Khan MHA,CPHQ Phd Harvard Am Med Inform Assoc. 2014 Sep-Oct;15(5):585-600.

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