Best Practices in EMR Implementation: A Systematic Review

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This is a review of Keshavjee, K., Bosomworth, J., Copen, J., Lai, J., Kucukyazici, B., Lilani, R., & Holbrook, A. M. (2006). “Best practices in EMR implementation: a systematic review.” [1]

First review


Implementing EHRs is a continuing endeavor which requires making a substantial investment from the very beginning of money, time and resources. It is crucial that these systems be put into operation successfully since stakeholders have high expectations for return on their investment as well as increasing constraints on funding for such projects. Current EMR implementation outlines have not delineated sufficient detail to help make the implementation process more efficient and successful.


This article details the initial step of the process: creation of a framework using literature discussing EMR implementation. A search from 1985 to 2006 in Medline HealthStar, EMBASE and DARE was carried out. The authors used keywords such as electronic medical records, associated MeSH words and “implementation” in their study. After eliminating many articles from the original list of over 1500, the authors used approximately 125 papers to build their framework.


The resulting framework which was produced emphasized factors that covered all three phases of EMR implementation: those being labelled by the authors as the pre-implementation phase, implementation phase and post-implementation phase. A few of the stated critical factors for implementation success as identified by the authors included: people with the vision, project management leadership, including your stakeholders in the process, ongoing support for users and incentives for users to continue using the system.


Roughly half of all EMR implementations fail leading to loss of finances, missed potential to improve patient outcomes and frustration from all those involved in the endeavor. The authors have created a very thorough and inclusive framework of factors which span the many aspects of EHR implementation. This article was an interesting read; it is also very informative as it lists many factors believed to be common to the successful implementation of EMRs. The authors concluded by stating that they are preparing a quantitative appraisal of the articles which will also provide statistical insights.

Second review

This article describes the common success factors to implement an EMR system using information from the assessment of 50 EMR implementations. Knowing the success factors prior to implementing EMR's is critical given the failure rates of EMR implementations is nearly 50% at the time this article was written.

The methodology of collecting the supporting information was collected from 125 Medline and Google searched articles over a ten year period from 1985 to 2006. The articles consisted of EMR implementations involving CPOE, stand alone EMR’s and where physician involvement was needed.

Below is a summary of the success factors during the pre-implementation and post implementation phase. These are critical to the success of clinical systems. The more success factors met, the more successful an EMR implementation will be.

  • Support from top management is important to ensure the needed resources are available and the importance of the project fits into the mission and values of the organization
  • A successful project manager is needed to promote, lead, organize and motivate project participants.
  • Change management techniques should be used to assess and prepare clinical staff for the upcoming EMR implementation - meaning it's important to be sensitive to the needs of clinical staff.
  • Involve a broad range of stakeholders to collect user requirements to ensure a broad buy-in.
  • Carefully choose software to ensure it meets user requirements and have users test-run the software prior to purchase.
  • Have a plan for integrating legacy data and ensure the new system integrates into other systems such as billing, labs, etc.
  • Ensure the software is user friendly with a short learning curve.
  • System must align closely with existing clinical workflows.
  • Recognize there is ongoing technical, training and emotional support to help clinicians understand and vent about the system.
  • Physician and patient security concerns must be met.
  • User groups should be available for ongoing clinician questions and training.
  • The benefits of EMR's such as easy access to patient data, cost savings and reduced error rates should be communicated to clinicians.

Comments: This article provided key suggestions for increasing the odds of a successful EMR implementation by using the experience of real world EMR implementations. The article provided little numerical evidence to support the success factors.

Third review


The article reviewed the importance of understanding how to best rollout EMR implementations. The emphasis was placed on framework development.


Previous reviews one and two provided information on methods.


The results were documented according to phases identified for EHR implementations:

  • Pre-implementation phase
    • Governance (People)
    • Project management leadership (People)
    • Sell benefits, manage attitudes, assessment of preparedness and address barriers (Process)
    • Involve multiple stakeholders (People)
    • Data pre-Load & integration (Technology)
    • Technology usability factors (Technology)
  • Implementation phase
    • Workflow and redesign
    • Training
    • Implementation assistance
    • Support
    • Feedback and dialogue
    • Privacy and confidentiality
  • Post Implementation phase
    • Technical support and business continuity
    • User groups
    • Incentives


The article did present findings in three phases of EHR (also known as EMRs)implementations Pre-Implementation, Implementation and Post Implementation. In addition, it included an illustration which showed the phases divided into the following subsets: people, process, and technology. For this review, it was helpful to understand how the findings correlated within a high level project plan. It was noted that the same number of findings were identified in both Pre-Implementation and Implementation stages. The initial stages of project delivery are equally as important as the execution stage; however, many projects do not always identify initial tasks or allocate time accordingly to perform the them in the pre-implementation phase. The more planning performed in the beginning, the smoother the execution phase.

Related papers


  1. Keshavjee, K., Bosomworth, J., Copen, J., Lai, J., Kucukyazici, B., Lilani, R., & Holbrook, A. M. (2006). Best practices in EMR implementation: a systematic review. In AMIA Annu Symp Proc (Vol. 982, p. 982).