EHR Implementation in Critical Access Hospitals (CAHs)

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EHR Implementation Barriers in Critical Access Hospitals

Implementation of an EHR is an overwhelming task no matter where it is done. However, achieving this task in a critical access hospital (CAH), which is defined as a hospital that provides 24-hour emergency services with less than 25 acute care and swing beds and is more than 35 miles from another hospital, with limited resources is more challenging. A recent study addressing this issue is EHR Implementation Advice to Critical Access Hospitals from Peer Experts and Other Key Informants].



  • 16 peer experts
  • 3 vendor representatives
  • 7 implementation experts
  • 6 EHR consultants
  • 3 CAH Regional Extension Center representatives
  • 4 researchers in clinical informatics and HIT policy
  • 2 national EHR policy stakeholders

These groups were split into CAH peer experts and all experts.

Questions asked of the participants:

  1. 1 "What are the things you'd want to know most about planning and preparation processes for EHR implementation at CAHs? Name two."
  2. 2 "What advice would you give CAHs on the planning and preparation processes for EHR implementation?"


19 themes, ranked in order of number of times mentioned, from expert comments:

  1. EHR Team
  2. Communication
  3. Clinician/Physician Buy-in/Ownership
  4. Budget/Financial Resources
  5. EHR System Selection
  6. Preparatory Work
  7. Technology
  8. Optimization/Ongoing Work
  9. Outside Partners/Information Resources
  10. EHR Training/Go-live Support
  11. Workflow/Productivity
  12. Project Management
  13. Purpose/Goals
  14. Leadership
  15. Change/Encouragement
  16. Policy/Meaningful Use
  17. Governance
  18. System Install/Go-live
  19. Clinical Decision Support/Knowledge Management

Reccuring Suggestions that Crossed Multiple Themes

Although some suggestions were specific to a theme, it is interesting that some suggestions were given with multiple themes. These included the suggestion that a group from the CAH travel to see each EHR in use at another CAH before purchase. This delegation should include key stakeholders at the institution as well as end-point users. The delegates should meet with their peers at the CAH already running the system and elicit comments about build, go-live, vendor support, difficulties, resolution of those difficulties, and ongoing use.

It was also mentioned across several themes to involve all departments including those who will use the system on a day to day basis, not just management. These employees can often give better feedback on how the system will work in the daily operations than department managers can.


Ranking of comments generated by CAH peer experts vs. all experts shows a different order of importance as well as 2 themes noted by non-CAH experts that were not noted at all by CAH experts. Also, when themes were ranked in order of concern by CAH experts they received a different order than when ranked by all experts as seen below.

Themes by expert commenters

  1. EHR Team
  2. Communication
  3. Clinician/Physician Buy-in/Ownership
  4. EHR System Selection
  5. Preparatory Work

Themes by CAH peer commenters

  1. EHR System Selection
  2. EHR Team
  3. Communication
  4. Preparatory Work
  5. Technology

This difference in ranking possibly points to all experts not understanding the differences of a CAH. For instance, whereas experts noted Clinician/Physician Buy-in/Ownership high (#3), CAH commenters noted it quite low (#12). CAHs often do not employ their physicians and the local physicians do not play major roles in operations. CAHs are also less likely to use hospitalists.


Important themes that affect implementation of an EHR in a CAH were found in this study. Lessons learned were to visit other CAHs early in the process and recurrently throughout EHR selection and implementation, communicate early and regularly from the EHR staff to the organization as a whole, investigate preparation and time required for EHR builds and to use outside resources besides just EHR vendors in decision making.

Some solutions to the barriers of introducing health IT (HIT) at rural hospitals is further discussed here: HIT Outsourcing in Rural Hospitals


Craven CK, Sievert MC, Hicks LL, Alexander GL, Hearne LB, Holmes JH. EHR Implementation Advice to Critical Access Hospitals from Peer Experts and Other Key Informants. Applied Clinical Informatics 2014; 5: 92-117