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How can stakeholder involvement be encouraged, and what can motivate pediatricians to adopt and use EHRs?

There are multiple stakeholders in pediatric electronic health records (EHRs) including providers, patients and families, payers, policymakers, and the public health community. Each of these stakeholders has unique sets of interests and needs. Getting stakeholder input early in the process will allow the stakeholders' needs to be more integrated into the EHR and to address stakeholder concerns before the system is implemented. Ultimately, getting stakeholder involvement entails addressing their needs with an EHR system that provides added value in order to improve health outcomes, quality, and efficiency.

Stakeholder needs include having a comprehensive medical record, reducing duplication of tests and overuse of certain treatments, creating efficiencies in the health care system, promoting patient safety, collecting and aggregating population health data, and facilitating the coordination of care. These needs may be shared by stakeholders for many reasons. The degree of importance of each need may also vary by stakeholder. Patients and families may wish to have a record that they can carry between providers, payers may wish to reduce their expenditures through reduced duplication and overuse, policy makers will be especially interested in quality and efficiencies, and providers will seek to coordinate care to provide comprehensive, high-quality care. EHRs are also valuable to public health agencies concerned with issues surrounding preparedness and vaccinations, particularly those issues involving the pediatric population. For example, EHRs can be used to provide information to biosurveillance programs to counteract illnesses affecting children such as the H1N1 Influenza. EHRs can also support public health programs such as immunization registries.

Electronic health records have the ability to provide value to multiple stakeholders in different ways. The ability of EHRs to perform these functions is highlighted by Nemours, which notes that electronic health records could greatly reduce delays in care that would occur in situations such as natural disasters like 2005's Hurricane Katrina. EHRs can also provide valuable data to public health researchers, who in turn can inform patient care in areas such as childhood obesity.go to exit disclaimer The EHR can also facilitate reporting, tracking, and surveillance of pediatric public health concerns. For example, the EHR-PH prototype detailed in an article from the American Medical Informatics Association (AMIA) Annual Symposium Proceedings in 2005 go to exit disclaimer utilized information from the EHR-Birth Record, including newborn metabolic disorder screening, newborn hearing screening, immunizations, and communicable diseases, and exchanged this information between the birth hospital and the appropriate public health programs. EHRs can also be successfully implemented in school-based health clinics (PDF - 780KB),go to exit disclaimer improving the coordination of care for children in a way that is convenient and timely for patients and families. The Early Childhood Immunization (ECI) program was developed to work with child-care and pediatric-care centers to potentially exchange information through the EHR to promote awareness and use of New Jersey's Immunization Information System (NJIIS). Payers too can benefit from EHRs and use them to better observe and manage the health of their beneficiaries.

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In general, providers have been reluctant to adopt and use EHRs. Though about 90% of pediatricians surveyed by the AAP go to exit disclaimer as far back as 1999 stated that they used computers to manage some aspects of patient care, the adoption of electronic health records by providers has been slow. Motivations such as the potential to improve the health outcomes and the quality of care of their patients are factors that can compel providers to adopt EHRs.  Providing evidence of these improvements from studies and from other practices can encourage providers who are contemplating EHR adoption. To motivate EHR adoption, however, the specific concerns of pediatricians need to be addressed as well.

There are many barriers that have limited widespread adoption of EHRs and providers may be concerned that the challenges could outweigh the benefits. Addressing these barriers and demonstrating that they can be overcome, can help motivate pediatricians to implement EHRs in their practices. Common barriers to adoption stem from challenges that relate to finances, technology, and concerns about their effect upon patient care.

Financial barriers to adoption and use of EHRs are common and include not only the initial cost of implementation but also a need for additional evidence of the return on investment. The reality for many providers is that they may have to assume most or all of the financial risk involved in adopting an EHR. Smaller and independent practices may face increased risk and longer waits for a return on investment according to a 2006 study appearing in Pediatrics.go to exit disclaimer When this risk overshadows potential rewards, such as improved quality and efficiency, then the motivation to adopt may fade. Providers may also be reluctant to invest in EHR systems if standards for the EHR system and technology, whether from the government or from industry, are not uniform or clear and do not reflect the unique needs of pediatric practices. A more detailed discussion of potential funding sources is discussed below.

Technological barriers to EHR adoption can arise from challenges relating to access to technology, knowledge and comfort levels, and a need for clear technology standards and technological support. Still, the technological change instituted by the EHR will also require workflow adjustments in the pediatric practice. This may initially disrupt productivity and efficiency as the office adapts to the new system. Pediatricians may worry that these changes could affect their ability to deliver timely, high quality care.

The degree to which barriers affect providers can be variable. The EHR can be a tool to help pediatricians improve the humanistic and business facets of their practices, and the benefits can be significant. Evidence of improvements stemming from EHRs, both anecdotal and empirical, has shown that these barriers can be successfully surmounted. Below are related resources, such as accounts of previous implementations and research studies that provide more in depth information along these lines.

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