May 2008

Document Type


Degree Name



Dept. of Biomedical Informatics and Clinical Epidemiology


Oregon Health & Science University


Objective: Implementation of an Electronic Medical Record (EMR) system in a primary care practice is a complex undertaking. This guideline availability and content analysis study examines the availability, relevance, consistency and interpretability of five publicly available implementation guidelines for use by the primary care provider. Perspective: This study focuses on the challenges facing primary care practices seeking to implement an EMR system on their own. The study setting is relevant for a new practice or for an existing paper-based practice. The main participant is the primary care practice manager or the individual assigned to oversee or guide the implementation in the practice. If the practice is small, the participant may be the physician leader of the practice. Methods: This study has two components. First, the availability of implementation guidelines is assessed using standard Internet search techniques. Ease or difficulty of finding guidelines is evaluated. Second, content analysis of key words in the identified guidelines is performed on the first and second level detail of the guidelines. Findings of the content analysis are used to evaluate the relevance, consistency and interpretability. Major Results: Results of this study indicate marginal guideline availability. The relevance of the guidelines to a primary care setting is rated high. Consistency of guidelines when compared to each other is judged to be medium to low. Finally, interpretability of guidelines is rated as medium. Conclusions: Locating guidelines is not straight forward. At present, the most reliable source of implementation guidelines is through practice specialty web sites, including those of the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). Available guidelines are designed for the primary care setting and present a structured approach through use of top level phases and detailed activity but when compared to each other, lack consistency. Further, the volume of detailed information presents a challenge for time-constrained practices to ingest, suggesting a voluntary versus directive approach. The voluntary implementation approach may impede attainment of a consistent, reliable and stable end state. Guidelines place greater emphasis on business components and less on technical aspects of implementation. No guideline provides an executive summary or quick reference guide. Academia, clinical informaticians, EMR vendors and healthcare standards organizations should unite to produce a single, standards based EMR implementation protocol. The resulting EMR Structured Life Cycle Protocol would well serve the primary care community by reducing risk and improving prospects for a successful outcome. This standard implementation protocol may also become candidate evaluation criteria for vendor selection, where EMR vendors demonstrate compliance to the standard. Sharing of the standard implementation protocol through all available communication venues, including practice specialty web sites, major health informatics advocacy sites and international standards sites would prove invaluable.




School of Medicine



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