. 2019 May 6;7(1):21. doi: 10.5334/egems.269

Table 3.

Factors that potentially affected the outcomes.

Contributing factor	Implementation-related	Outcome(s) impacted	Explanations

Decrease in communication	Yes	ED LOS^ir ED wait time^ir	Due to CPOE adoption, communication between providers decreased and interruptions increased
Incomplete data migration	Yes	Laboratory orders^d	Partial data were migrated from the legacy systems to the new EHR compromising accuracy of overdue test alerts
Increase in staff	Yes	ED LOS^ir ED wait time^ir Patient visits^dr	12 ED nurses were hired prior to the go live Some PC physicians employed scribes to facilitate clinical documentation and recovery of patient visits
Learning curve	Yes	ED LOS^ir ED wait time^ir Patient visits^dr New patient visits^d	Due to new functionality to learn, efficiency decreased and recovery to baseline levels took longer than expected
Missing functionality	Yes	Blood pressure^d	Due to missing functionality, clinicians were unable to override a temporary hypertension to consider the patient “in control”
Redistribution of staff or work	Yes	ED LOS^ir ED wait time^ir Patient visits^dr New patient visits^d Abdominal hysterectomyⁱ Colon surgeryⁱ	ED Physicians decreased their patient ratios for three days only Patients were oriented to arrive earlier for their visits to recovery to normal levels of patient visits Some preventive tasks were redistributed to keep up with increased SSI cases detected
Resistance to learning or using a new EHR	Yes	Employee turnover^ir	Some clinical personnel quit to avoid learning or using a new EHR In some cases they anticipated their retirement
System configuration	Yes	Laboratory orders^d Time documenting after hoursⁱ Abdominal hysterectomyⁱ Colon surgeryⁱ MRSA infections^dr CDiff infections^d	Laboratory alerts were added progressively PC providers used a mobile app to complete visit documentation The new EHR had a more robust capability for capturing potential infections, which was improved over time
Workarounds	Yes	Blood pressure^d Laboratory orders^d Time documenting after hoursⁱ	Physicians started using nurses’ triage measurement of BP; the lack of double-check for measurement may have led to inaccurate BP in some cases The process for collecting lab samples at the clinics was redesigned due to CPOE adoption Physicians modified their schedules and workflow practices in order to complete electronic documentation
Change in care pathways	Partially	Readmission rate^d	Improvements to care pathways partially introduced by the EHR may have contributed to a decrease in readmissions
Intentional decrease in volume of work	Partially	Patient visits^dr New patient visits^d Laboratory orders^d	Physicians were seeing fewer patients in order to complete electronic documentation
Health insurance changes	No	Diabetes bundle^d Patient visits^dr New patient visits^d Laboratory orders^d Time documenting after hoursⁱ	Patients with health savings accounts tend to avoid chronic disease management visits which hampers management of diabetes outcomes Insurance companies stopped covering the most common tests in physical exams potentially decreasing lab orders Insurance companies started to require more strict coding of procedures contributing to longer documentation times
Patient Engagement	No	Diabetes bundle^d	Half of the bundle items depend mostly on patient engagement on treatment
Seasonal pattern	No	ED visits^ir ED LOS^ir ED wait time^ir	The go live was postponed due to problems in previous regions and happened in a time of a slight pick

ⁱ Denotes a significant increase with no recovery to the baseline level;

^d Denotes a significant decrease with no recovery to the baseline level;

^ir Denotes a significant increase with recovery to the baseline level;

^dr Denotes a significant decrease with recovery to the baseline level.

Abbreviations: EHR: electronic health records; CPOE: computerized provider order entry; BP: blood pressure; PC: primary care; ED: emergency department; LOS: length of stay; HF: heart failure; CDiff: Clostridium Difficile; MRSA: Methicillin-resistant Staphylococcus aureus; SSI: surgical site infection.