Technical challenges

To summarise, more primary care physicians than the other specialities (Linder al 2006, NCHS 2013) and more nurses than physicians showed positive attitudes towards eHealth applications. The barriers for using ICT in healthcare services vary between different professional groups (Darr et al 2003, Linder al 2006, Ward et al 2008, Rahimi et al 2009, NCHS 2013). The reasons mentioned by different professional groups were varied and included factors such as reduced time for patient care (Kossman 2005), disruption of the traditional roles and responsibilities and change in providers‟ role as data entry clerk (Hellström 2009; Georgiou 2009,Boonstra, Broekhuis 2010, Mair et al 2012), loss of professional autonomy and control over patient information (Boonstra, Broekhuis 2010), heavier administrative tasks (Darr, Harrison, Shakked & Shalom 2003) and limitation of critical thinking (Kossman 2008; Georgiou 2009). In addition, lack of adequate valid statistical data and success stories about EMRs to convince the non-users or the non-adopters could be perceived as a barrier (Boonstra and Broekhuis 2010).

2.3.3 Technical challenges

In addition to a range of interrelated individual and organizational issues, the implementation of eHealth should take into account the technical challenges such as the need for flexibility and usability, appropriate education and training and the need for the software to be „fit for purpose‟ (Boonstra and Broekhuis 2010, McGinn et al 2011).

Each user group of EMR has factors specific to their professional and individual priorities commonly related to technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity, motivation, patient and health professional interaction and workload (Boonstra and Broekhuis 2010).

2.3.3.1 Software or hardware

Technical limitations related to software or hardware such as speed, design, inappropriate development tools, improper documentation, weak test planning, unplanned downtime and obsolescence were most frequently cited as barriers that contribute to failures (Boonstra and Broekhuis 2010, McGinn et al 2011). According to a systematic review of McGinn et al (2011), technical concerns were mentioned by 42.3%

(n= 52 studies).

Jose et al (2005) showed that physicians‟ satisfaction with the implementation of EMR was positively correlated with their perception of EMR speed (Spearman‟s rho = 0.3; p = 0.04), outside access (Spearman‟s rho = 0.5; p = 0.002), and EMR efficiency (Spearman‟s rho = 0.4; p = 0.008).

Fear of the possibility of record loss due to technical defects arising from computer crash, viruses and power failure was also raised as a concern by physicians in several research studies (Boonstra and Broekhuis 2010).

System flexibility is another challenge. The system should be flexible enough to support practices ranging from small solo practices to national integrated delivery networks and should be able to generate quality reports for a variety of health plans (Kaplan & Harris-Salamone 2009, McGinn et al 2011).

Another concern reported in the study done by DesRoches et al (2008), system obsolescence was mentioned as a major concern by 27% of those adopting EMR and 44% of those not adopting any EMR. In another study by Roa et al (2011) concerns on system obsolescence were mentioned by 47% of physicians of 1 – 2 practices, 41% of physicians of 3-5 practices, 40% of physicians of 6-10 practices and 34% physicians of 11+ practices. System obsolescence was found to be a more significant concern for practices not having any EMR and small practices.

To conclude, healthcare providers were mainly concerned about technical issues like the speed, the design, weak test planning, the flexibility and obsolescence the system which should be addressed during planning, development, testing and implementation stages (Jose et al 2005, DesRoches et al 2008, Bonnie 2009, Boonstra and Broekhuis 2010 and McGinn et al 2011).

2.3.3.2 Interoperability

Achieving interoperability to ensure communication between different technologies and software applications for the efficient, accurate, and sound sharing and use of data of clinical information is a key to making EHR use a cornerstone of practice and a fully standardized interoperability could save the nation $77.8 billion annually (Bates 2005).

Interoperability represents a widely recognized obstacle because of the presence of the multitude of EHR/EMR software types with different packages that do not interoperate

well with each other, mainly because of lack of data exchange standards (Bates 2005, Boonstra and Broekhuis 2011).

Inadequate interoperability (interfacing) due to lack of standards, regulation, guidelines and technical specifications during health data exchange was generally perceived as a barrier in 19.2% (n= 52 studies) of the studies (McGinn et al 2011). eHealth standards include metadata standards, messaging standards and medical record standards(WHO 2009),

2.3.3.3 Privacy and security

Privacy and security was the one of the most frequently mentioned concerns because breach of security could be more catastrophic than in a paper-based system. This could undermine confidence in eHealth utilization and hinder the movement from a paper-based system towards electronic records (Bates 2005, McGinn et al 2011, Mair et al 2012). All user groups (physicians, other healthcare professional and managers) reported concerns over any factors that could compromise the security or confidentiality of patient (McGinn et al 2011). However, Simon et al (2007) showed privacy and security to be the least positively viewed benefits by both EHR adopters and non-adopters. Only less than a third of respondents, 29.9% high users, 32.9% low users and 23.0% non-adopters agreed that EHR could improve patient privacy. Kemper, Uren &

Clark (2006) also showed privacy and confidentiality to be among the least positively perceived benefits, 64.4% among the adopters and 49.3% among the non-adopters.

Studies by Kemper et al (2006) and Simon et al (2007) showed that non-adopters have statistically lower positive attitudes towards the security offered by EHR.

Concerns about privacy and security were high among physicians because of the legal consequences of inappropriate disclosure (Simon et al 2007, Boonstra & Broekhuis 2011). The concern was further aggravated by lack of clear security regulation and standards in some countries to protect the privacy of patients and the confidentiality of their medical information (Boonstra & Broekhuis 2011).

On the other hand, privacy and security concerns of patients were mixed. Five studies reported that confidentiality and security were of little concern among patient participants while four studies raised some concerns (McGinn et al 2011). Many of the studies indicated that the level of concern raised by the patients on privacy and security issues was less significant than that of the healthcare providers‟ (McGinn et al 2011).

On the other hand, a study by Ancker et al (2012) found that half of the healthcare consumers (patients) believed that EHR would compromise privacy and security.