TABLE 4.

Representative quotes on culture related concepts in health information technology implementations

Theme	Sub‐theme	Sample quote
Culture stress (n = 34)	Facilitator (n = 0)	NA
	Barrier (n = 21)	“[The participants] articulated that the volume of work shifted to [the staff] was very high and that they were understaffed … Overall, participants felt that there was not a sufficient numbers of [staff] in their organization and that these [staff] were under‐resourced.” (Chipps et al 26 )
	Both (n = 11)	“The informant reported that initially there was ‘anticipatory panic’ expressed by medical assistants about fitting the additional work into the clinical workflow. However, once staff started using the platform and were able to see positive effects on patients' lives, they became more enthusiastic about the technology.” (Cartier et al 25 )
	Not Stated or Unclear (n = 2)	“In practices where communication patterns are more fragmented, EHR support staff may need to work with each individual to achieve EHR use goals set by the larger organization.” (Lanham et al 73 )
Culture effort (n = 27)	Facilitator (n = 21)	“both primary care providers and specialists considered themselves to have shared responsibility for problem list maintenance” (Wright et al 62 )
	Barrier (n = 1)	“I have seen prescribers simply ‘not act’ to reconcile a medication because there was insufficient information or they were not sure” (Rangachari et al 33 )
	Both (n = 1)	“[The authors] viewed this resistance as an invitation to educate leaders, providers, and staff about LGBT health disparities and to expose providers to techniques” (Callahan et al 56 )
	Not Stated or Unclear (n = 4)	“Managing the culture, it is what it is. The most you can do is find, like a good physician champion, find a strong practice leader.” (McAlearney et al 59 )
Implementation climate (n = 38)	Facilitator (n = 17)	“…the decision to pursue [an HIT implementation] stemmed from a culture of innovation, particularly regarding initiatives to improve patient safety and organizational efficiency” (Chaturvedi et al 30 )
	Barrier (n = 8)	“…physicians did not view their role as active translators of the technology to their local setting. In other words, because physicians felt that the [HIT implementation] was not customized to local needs, resistance was engendered, rather than acceptance” (Muslin et al 66 )
	Both (n = 3)	“In our case, oncologists were not incentivized to review PROs, whereas surgeons could receive additional payment for including PRO assessment” (Zhang et al 34 )
	Not Stated or Unclear (n = 10)	“Cultural shifts within a clinical area are required to promote sustained practice change. The cultural shift toward early mobility started in 2010 … yet integration of early mobility as a cultural norm continued to be a work in progress” (Anderson et al 35 )
Learning climate (n = 18)	Facilitator (n = 10)	“The importance of institution wide educational efforts in resolving user workflow problems cannot be emphasized enough.” (Chung et al 38 )
	Barrier (n = 2)	“a lesson here is simply having a training program is not sufficient; providing physicians with a set of instructions for using the ordering software will not necessarily create buy‐in” (Muslin et al 66 )
	Both (n = 3)	“One clinician commented, ‘occasionally things pop up and I have to learn how to do it but after a few times, you learn how to make it faster.’ Another felt she navigated the [new] screen quite well and adapted the screen to meet her needs.” (Tobler et al 49 )
	Not Stated or Unclear (n = 3)	“The first phase of implementation consisted of staff participation in an online educational module … Although completion of the eMobility module was not tracked by individual staff participants, the postimplementation survey asked whether the module was viewed and helpful.” (Anderson et al 35 )
Readiness for implementation (n = 18)	Facilitator (n = 6)	“organizational innovativeness is likely associated with more forums associated with the technology, including workshops, seminars, and email groups. These outlets create opportunities for employees to ask each other for advice and help” (Barrett 36 )
	Barrier (n = 1)	“Physicians here viewed their role simply as passive implementers of a standardized technology package. A physician stated: “The training and implementation left much to be desired.” (Queenan and Devaraj 54 )
	Both (n = 1)	“One practice was very engaged about change and implementation of technology, while the other was somewhat resistant to change and wary of e‐prescribing feeling it was not make prescribing safer with less prescribing errors.” (Kooienga and Singh 44 )
	Not Stated or Unclear (n = 10)	“Informants at all our sites recognized that some potential EHR users, mainly clinicians, did not have basic computer literacy and skills. Several of the sites recognized this need and developed pre‐implementation skills assessments.” (McAlearney et al 74 )
Leadership engagement (n = 37)	Facilitator (n = 13)	“Support from high level management was instrumental to success and played a critical role in communicating the organizational vision, the expectation for clinician engagement, and that the PHR implementation was the organization's policy” (Wells et al 68 )
	Barrier (n = 5)	“Though most leadership expressed strong support for eScreening in individual interviews, many staff focus group participants sensed a lack of enthusiasm for the project either because of little to no communication from the top.” (Pittman et al 32 )
	Both (n = 3)	“Several of the primary barriers (eg, openness/buy‐in) were centered on collective attitudes and perspectives of those within the organization, such as leaders in the position of making clinical care (and therefore adoption) decisions, about technology‐based approaches…. Successful implementation is more likely in climates with motivation to change, that are flexible for embracing innovation, and that have leadership support and infrastructure resources to support the innovation.” (Ramsey et al 55 )
	Not Stated or Unclear (n = 16)	“Specifically, top‐down communication must clearly delineate strategies and tactics for achieving system standardization, processes for change management decisions, the capability of the EHR, and expectations for professional competencies.” (Collins et al 57 )
Available resources (n = 42)	Facilitator (n = 4)	“However, leadership reported making an early decision to commit the necessary financial requirements for implementation—even when it became clear that the staff time investment was significantly larger than initially expected.” (Creber et al 39 )
	Barrier (n = 12)	“A challenge at all four demonstration sites was securing the technical, clinical and informatics resources needed to complete the implementation.” (Wright et al 61 )
	Both (n = 5)	“Physicians noted that training tailored to their role helped them to adapt to using the EHR. For example, as one physician told us, “I think if it's very specific, and it's sort of triggered by the provider… then they think, they'd probably accept it pretty well. But, if it's sort of imposed, probably not.” (Sieck et al 28 )
	Not Stated or Unclear (n = 21)	“The organization mobilized over 600 super users who received extra training and were pulled out of staffing to offer at‐the‐elbow support 24/7 for the first 2 weeks.” (Bentley et al 51 )