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Challenges to EHR Implementation in Electronic- Versus Paper-based Office Practices

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Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems.


To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based).


Qualitative study.


Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006.


Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0.


We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome.


Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.

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This study was supported by grants from the United Hospital Fund and the NewYork-Presbyterian Hospital. We would particularly like to thank Dr. Mary Cooper at the New York-Presbyterian Hospital for her support of this project. This study was presented at the Pediatric Academic Societies’ 2007 annual meeting held in Toronto, Canada.

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Correspondence to Stephanie O. Zandieh MD, MS.

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Zandieh, S.O., Yoon-Flannery, K., Kuperman, G.J. et al. Challenges to EHR Implementation in Electronic- Versus Paper-based Office Practices. J GEN INTERN MED 23, 755–761 (2008).

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