Last week I taught Module II of Leadership Strategies for Information Technology in Healthcare at the Harvard School of Public Health.

My students included administrators, clinicians, CIOs, CMOs, and policymakers.

On the first day, I gave them a homework assignment - read my overview of the BIDMC/BIDPO EHR implementation project and then develop a list of barriers to EHR implementation in their organizations.

Here's the crowd sourcing results of the top 10 barriers to successfully deploying an EHR:

10. Usability - products are hard to use and not well engineered for clinician workflow.

9. Politics/naysayers - every organization has a powerful clinician or administrator who is convinced that EHRs will cause harm, disruption, and budget disasters.

8. Fear of lost productivity - clinicians are concerned they will lose 25% of their productivity for 3 months after implementation. Administrators are worried that the clinicians are right.

7. Computer Illiteracy/training - many clinicians are not comfortable with technology. They are often reluctant to attend training sessions.

6. Interoperability - applications do not seamlessly exchange data for coordination of care, performance reporting, and public health.

5. Privacy - there is significant local variation in privacy policy and consent management strategies/

4. Infrastructure/IT reliability - many IT departments cannot provide reliable computing and storage support, leading to EHR downtime.

3. Vendor product selection/suitability - it's hard to know what product to choose, particularly for specialists who have unique workflow needs

2. Cost - the stimulus money does not flow until meaningful use is achieved. Who will pay in the meantime?

1. People - its's hard to get sponsorship from senior leaders, find clinician champions, and hire the trained workers to get the EHR rollout done. (this was the #1 concern by far)

After we reviewed the real top 10 list, I read a more colorful top 10 list in the Letterman tradition, from a very creative student

10. You need to attend a Harvard Certificate Program to have a clue

9. Meaningful use is only meaningful to academic scholars

8. Docs keep asking - where's my money?

7. The government thinks 2011 is a decade away

6. The government says "do it now, but I will tell you what I want next month"

5. My kids say "hey Dad, I just discovered 10% (i.e. the inpatient CPOE usage requirement) is a passing grade"

4. You read about your security breaches in the New York Times.

3. Patients get to go home early because clinicians are busy implementing software.

2. When you ask vendors how they justify the claim that their products are 2011 certified (and the certification process has not yet been announced), they show you a Ouija Board.

1. You need Ted Williams' batting statistics to convince your Board that EHRs are worthwhile.

There you have it - the actual top 10 from the crowd and the wisdom from someone who's keeping their sanity during this time of great change with a touch of humor.

John Halamka, MD, blogs regularly at Life As a Healthcare CIO.