key: cord-0785809-debkp693 authors: Jung, Se Young; Lee, Keehyuck; Lee, Ho-Young; Hwang, Hee title: Barriers and Facilitators to Implementation of Nationwide Electronic Health Records in the Russian Far East: A Qualitative Analysis date: 2020-08-02 journal: Int J Med Inform DOI: 10.1016/j.ijmedinf.2020.104244 sha: ff15e319dd1370c1ab19f45b2717401fed2f8a43 doc_id: 785809 cord_uid: debkp693 BACKGROUND: Electronic health records (EHRs) are transforming and revolutionizing the healthcare industry. However, whereas developed countries have a high EHR penetration rate, adoption of EHRs in developing countries is lagging behind. Recently, the Korean and Russian governments have been pursuing economic cooperation in the Russian Far East. Thus, since 2009, Russia’s EHR market and healthcare system have been maturing in tandem. OBJECTIVE: To qualitatively investigate and analyze the current status of EHRs in the Russian Far East and derive implementation plans for nationwide EHRs. METHODS: A qualitative analysis based on semi-structured interviews with healthcare professionals and administrative officers in the Russian Far East was conducted to illuminate the current status of EHRs and to collect various perspectives on barriers and facilitators to implementation. RESULTS: The analysis revealed six major barriers and five major facilitators for implementation of nationwide EHRs in the Russian Far East. The barriers include lack of communications, an insufficient system development environment, poor adoption of standard terminology, poor infrastructure, resistance to a new system, and poor functionality. Facilitators include strategic government planning, centrally managed systems, health information exchange, willingness to use new functions, and well-established work processes. CONCLUSIONS: This study’s results, along with the experiences of developed countries that have already successfully introduced EHRs, will help support successful introduction of EHRs in the Russian Far East. Digital transformation is revolutionizing in healthcare industry. [1, 2] At the heart of this revolution are electronic health records (EHRs). [3, 4] In 2009, the United States implemented the Health Information Technology for Economic and Clinical Health (HITECH) Act, prompted by evidence that EHR use improved the quality of healthcare. [5] By 2017, 96% of general medical and surgical hospitals, 89% of rehabilitation centers, 87% of children's hospitals, and 59% of acute long-term care hospitals in the US had begun to utilize certified EHRs. [6, 7] South Korea also has a high EHR penetration rate; the Health Insurance Review and Assessment Service (HIRA) indicated that as of 2017, 93.6% of hospitals and 91.6% of private clinics in the country had adopted electronic medical record (EMR) systems [8] However, EHR adoption rate in developing countries is lagging. Nationwide implementation of EHRs is urgently needed to improve healthcare quality in these countries. disseminate EHRs. However, few studies have explored the barriers and facilitators to implementation of nationwide EHRs. This study aimed to qualitatively investigate and analyze the current status of EHR implementation in the Russian Far East, and thereby to derive a plan for nationwide implementation of EHRs. The research was conducted in two stages. First, semi-structured interviews were conducted to examine the working environment, IT status, and EHR implementation in hospitals in the Russian Far East. Next, based on the survey, a master plan for the development of the target system was established. By conducting qualitative analysis based on semi-structured interviews with healthcare professionals and administrative officers in Russian Far East, this study sought to reveal the current status of EHRs in the region and to collect various perspectives on barriers and facilitators to EHR implementation. To conduct qualified qualitative research, this study followed Consolidated Criteria for Reporting Qualitative (COREQ) Research Guidelines. [20] This study's semi-structured interviews were conducted at the state medical information center of Primorsky Krai, the Sixth Outpatient Hospital, a national children's hospital, a private children's hospital, the Far Eastern Federal University Hospital, and the Primorsky Krai Department of Health. To design the qualitative semi-structured interview questionnaire, a preliminary survey was conducted with 13 chief executive officers of the Moscow Health Department Municipal Hospital, who visited Seoul National University Hospital (SNUBH) to participate in educational programs. Basic information on the 13 participants and the interview results of the interview are presented in Supplementary Table 1 . The pre-interview was designed based on the factors considered to be important for the introduction of EHR at the national level with reference to the certification of HIMSS EMRAM. The detailed criteria we adopted from the certification is provided in supplementary material. The preliminary questionnaire included 55 questions in nine areas: 1) Type and size of hospital; 2) Type and size of workforce; 3) Number of hospital visits; 4) Information strategy plan and dedicated department; 5) Information infrastructure (network, computer equipment, medical information system) and maintenance; 6) Medical information exchange; 7) Necessity of a medical information certification system; 8) Information security (personal information security and infrastructure security); and 9) National support plans for to promote informatization. Based on the preliminary questionnaire, a basic questionnaire was constructed, as shown in Table 1 . The study participants were selected through purposive sampling. [21] The goal was to include participants from various professions who had an in-depth knowledge of the work processes involved with EHRs and the hospital IT environment in the Russian Far East. Data were collected through face-to-face, semi-structured interviews. Professionals Exploratory content analysis was employed to capture interviewees' perspectives on implementation of nationwide EHRs in the Russian Far East. The recorded interviews were transcribed by the researchers, with repeated rounds of review and correction to enhance the accuracy of the transcriptions. To ensure reliability, the transcripts were independently read and coded by two individual researchers (SYJ and HYL). The initial codes were generated inductively from the data and grouped into three major themes by each profession: hospital IT environment; barriers and facilitators; and ideas for strategic implementation of nationwide EHRs. Themes identified as relevant to the study were discussed until SYJ and HYL agreed that they had reached saturation. All researchers verified the results and formed a consensus on the clarified themes. Before conducting the interviews, the researchers explained the research objectives and Interviews were conducted between October 2 and October 4, 2019. The 25 total participants included six physicians, one nurse, three pharmacists, eight IT developers, four government officers, and three executive officers. Participants' demographic characteristics are presented in Table 2 . Detailed information on representative participants in each institution is provided in supplementary material. Six significant barriers to implementing nationwide EHRs were identified, related to the current IT environment in hospitals. Russia has legally allowed telemedicine since January 2018. By 2020, more than 20% of Russia's population is expected to utilize remote healthcare. Russia has also set a goal to gradually implement nationwide EHRs by 2024, led by the central government. Therefore, an EHR adoption strategy must these legal and policy changes into account. The study's participants were aware of the government's general policy direction, but not its specific methods or strategies. Therefore, the central and local governments should continue to communicate with local hospitals on the introduction of nationwide EHRs. "Our hospital has its own medical information system [ Russia's healthcare system is highly centralized. [22] Most IT developers who participated in this study anticipated that Russia's poor infrastructure would hamper adoption of EHRs. In particular, many concerns were expressed J o u r n a l P r e -p r o o f regarding the environment for EHR development and operation. Russia has been working to implement nationwide healthcare infrastructure since the early 2000s. [26] A UK Trade and Investment report indicates that the Russian government has committed approximately USD 7 billion to healthcare infrastructure upgrades, [27] and the Russian 2020 Health Program aims to improve the efficiency and accessibility of healthcare. [28] It also plans to improve and complement the infrastructure and medical services in the healthcare sector, introduce customized medical services, and foster new health workers. Nevertheless, the medical IT developers interviewed in this study noted that the development infrastructure for EHRs is still lacking, an issue that must be resolved before nationwide EHRs can be implemented successfully. For the government's EHR distribution project to succeed, its infrastructure improvement project, which has already been in progress for 20 years, should be accelerated to establish an adequate technical environment introduction of EHRs. To successfully disseminate nationwide EHRs and facilitate meaningful exchange of medical information an international standard terminology framework must be introduced. Terminology standards such as SNOMED-CT, ICD-10-CM or ICD-9-CM, RxNorm, LOINC, WHO-ATC, and ICNP 2.0 should be actively introduced from the start of EHR development. Additionally, all job divisions in hospitals, not only medical staff, should employ the standard terminology so that medical big data can be used in a valuable way. For example, although the United States has successfully implemented government-led EHR dissemination programs, it still suffers from deficits in HIE. To avoid such difficulties, Russia must successfully facilitate HIE from the initial introduction of EHRs. Older staff members exhibited general anxiety regarding new systems. This finding is similar to a previous study that found age to associate with people's satisfaction with EHR adoption. [29, 30] Older age is related to lower computer literacy. Thus, the skill sets needed to handle tasks using EHR systems can vary by age group. A number of older staff members were not exposed to computers in the past. This can be solved through well-executed training programs, which should be prepared to provide and make new EHR systems accessible to all age groups. Overall, hospitals and government agencies in the Russian Far East are eager to introduce nationwide EHRs, but the technical, social, and institutional conditions do not yet support widespread implementation. In particular, the federal government has not shared details of its EHR development plan with local governments and hospitals, leaving them unclear on the direction and expectations of the system. Even in the development process, the federal government must work with local governments and hospitals to ensure that EHRs satisfy the functions required by actual users. Russia has already introduced telemedicine in 2018, and aims to implement healthcare ICT by 2020, with the goal of providing telemedicine to 20% of Russia's population. [ important to discover ideas from private institutions and improve the system based on them to spread them nationwide. Moreover, efforts should be made to improve user awareness and system deployment. EHR dissemination at the national level is not just a simple process of installing the system; it is a comprehensive procedure to introduce standards of medical practice through standard EHR to reduce costs in hospitals and raise the quality of medical care. As seen in examples of collaborative research in international health and medical crisis situations such as the coronavirus disease (COVID-19) pandemic, the infrastructure for medical information exchange must be designed to meet international standards in the first place so that it is possible to exchange medical information while reducing costs in the future. [33] When the standard system is actively introduced by the central government, a foundation environment is established in which various companies can continue to grow by adhering to the standard system. Second, the government should develop a solid reimbursement plan. The U.S. has rapidly increased its EHR penetration rate in a short span of time based on the reimbursement plan. [6] Korea was able to disseminate PACS in the medical imaging field nationwide in the early 2000s thanks to the national reimbursement policy. [34] Third, cooperations between the central and local government as well as government and private entities are also important. As in the case of the private children's hospital, the private sector already has HIE and PHR as needed. To effectively and efficiently spread EHR at the national level, it is important to discover ideas from private institutions and improve the system based on them to spread them nationwide. Moreover, efforts should be made to improve user awareness and system deployment. EHR dissemination at the national level is not just a simple process of installing the system; it is a comprehensive procedure to introduce standards of medical practice through standard EHR to reduce costs in hospitals and raise the quality of medical care. J o u r n a l P r e -p r o o f This study's strengths include the breadth of clinical disciplines and experience reflected by the interviewees, all end users of EHRs in the Russian Far East Russia. Users from four hospitals and government officers actively participating in nationwide EHR projects were surveyed to investigate barriers and facilitators to introducing nationwide EHRs in detail. Interviews were qualitatively analyzed to understand the factors important to healthcare professionals, IT developers, and government officers. The study is limited in that participants were recruited from small number of hospitals in the Russian Far East. Therefore, the issues identified may apply only to the local area. However, the study attempted to obtain insights that could be generalized as much as possible, having no dependence on a specific area or system, to derive lessons that can be applied to national planning, especially in a large developing country like Russia. Future research should collect various opinions from additional hospitals to examine whether the barriers and facilitators proposed in this study apply equally to other healthcare environments. EHRs represent a key aspect of healthcare revolution, allowing hospitals to standardize their work processes, improve care quality, and reduce costs. This study identified six barriers and five facilitators to adoption of nationwide EHRs in the Russian Far East. 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