Electronic health record system implementation processes at critical access hospitals

[ACCESS RESTRICTED TO THE UNIVERSITY OF MISSOURI AT AUTHOR'S REQUEST.] The US government allocated $30 billion to implement electronic health records (EHRs) in hospitals and provider practices through policy addressing Meaningful Use (MU). Most small, rural hospitals, particularly those designated as Critical Access Hospitals (CAHs), comprising nearly a quarter of US hospitals, had not implemented EHRs before. Little is known about implementation in this setting. Socio-technical factors differ between larger hospitals and CAHs, which continue to lag behind other hospitals in EHR adoption. Qualitative methods employing Glaserian Grounded Theory were used to develop question protocols and conduct 69 interviews and eight focus groups onsite at four CAHs in Arkansas (1), Kansas (2), and Tennessee (1) where staff were undertaking EHR implementation. In addition, 41 phone interviews were conducted with a spectrum of implementation experts, including newly-minted peer-experts from 10 additional CAHs, who had completed EHR implementations. Twenty-eight themes emerged from coding and analysis. Key barriers and facilitators for EHR implementation at CAHs were identified, and a prospective implementation framework for hospitals for these and similar, small rural hospitals was developed, with additional recommendations for ehealth policy makers and other stakeholders