Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

Supporting Special-Purpose Health Care Models via Web Interfaces

The potential of the Web, via both the Internet and intranets, to facilitate development of clinical information systems has been evident for some time. Most Web-based clinical workstations interfaces, however, provide merely a loose collection of access channels. There are numerous examples of systems for access to either patient data or clinical guidelines, but only isolated cases where clinical decision support is presented integrally with the process of patient care, in particular, in the form of active alerts and reminders based on patient data. Moreover, pressures in the health industry are increasing the need for doctors to practice in accordance with ¿best practice¿ guidelines and often to operate under novel health-care arrangements. We present the Care Plan On-Line (CPOL) system, which provides intranet-based support for the SA HealthPlus Coordinated Care model for chronic disease management. We describe the interface design rationale of CPOL and its implementation framework, which is flexible and broadly applicable to support new health care models over intranets or the Internet

Evaluating tools to support a new practical classification of diabetes: excellent control may represent misdiagnosis and omission from disease registers is associated with worse control.

To conduct a service evaluation of usability and utility on-line clinical audit tools developed as part of a UK Classification of Diabetes project to improve the categorisation and ultimately management of diabetes

Acceptance model of electronic medical record

This paper discusses acceptance issues of Electronic Medical Record System (EMR), particularly in Malaysia. A detailed overview of EMR and its benefits are firstly discussed. A number of acceptance models are scrutinized. Then factors affecting EMR acceptance are put forward. Finally, before proposing an EMR acceptance model, an instrument formed by adapting and then finding its factors loading is presented

MOSAIC roadmap for mobile collaborative work related to health and wellbeing.

The objective of the MOSAIC project is to accelerate innovation in Mobile Worker Support Environments. For that purpose MOSAIC develops visions and illustrative scenarios for future collaborative workspaces involving mobile and location-aware working. Analysis of the scenarios is input to the process of road mapping with the purpose of developing strategies for R&D leading to deployment of innovative mobile work technologies and applications across different domains. One of the application domains where MOSAIC is active is health and wellbeing. This paper builds on another paper submitted to this same conference, which presents and discusses health care and wellbeing specific scenarios. The aim is to present an early form of a roadmap for validation

Benefits and problems of electronic information exchange as perceived by health care professionals: an interview study

<p>Abstract</p> <p>Background</p> <p>Various countries are currently implementing a national electronic patient record (n-EPR). Despite the assumed positive effects of n-EPRs, their overall adoption remains low and meets resistance from health care providers. This study aims to increase our understanding of health care providers' attitude towards the n-EPR, by investigating their perceptions of the benefits and problems of electronic information exchange in health care and the n-EPR in particular.</p> <p>Methods</p> <p>The study was conducted in three Dutch health care settings: acute care, diabetes care, and ambulatory mental health care. Two health care organisations were included per setting. Between January and June 2010, interviews were conducted with 17 stakeholders working in these organisations. Relevant themes were deduced by means of thematic qualitative analysis.</p> <p>Results</p> <p>Health care providers perceived electronic information exchange to promote the efficiency and quality of care. The problems they perceived in electronic information exchange mainly concerned the confidentiality and safety of information exchange and the reliability and quality of patient data. Many problems perceived by health care providers did not specifically apply to the n-EPR, but to electronic information exchange in general.</p> <p>Conclusions</p> <p>The implementation of the Dutch n-EPR has mainly followed a top-down approach, thereby neglecting the fact that the perceptions and preferences of its users (health care providers) need to be addressed in order to achieve successful implementation. The results of this study provide valuable suggestions about how to promote health care providers' willingness to adopt electronic information exchange, which can be useful for other countries currently implementing an n-EPR. Apart from providing information about the benefits and usefulness of electronic information exchange, efforts should be focused on minimising the problems as perceived by health care providers. The safety and confidentiality of electronic information exchange can be improved by developing tools to evaluate the legitimacy of access to electronic records, by increasing health care providers' awareness of the need to be careful when using patient data, and by measures to limit access to sensitive patient data. Improving health care providers' recording behaviour is important to improve the reliability and quality of electronically exchanged patient data.</p

Patient-specific computer-based decision support in primary healthcare-a randomized trial

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