Introduction
This paper reports on our findings from a systematic literature review of previously reported EHR (electronic health record) implementations, undertaken to gain a comprehensive understanding of the current state of EHR implementation. In this paper, we refer to EHR as any health, clinical or medical records in electronic or digital format, in the context of patient care. This paper aims to describe the system attributes (information quality, system quality and service quality), levels of use and satisfaction, and impacts of EHR as perceived by clinical users (doctors and nurses) and patients, and contingent factors relating to system implementation (development, implementation and organisational).
EHR implementations are widespread and have been well recognised as costly investments. According to an industry report by Accenture [1], from 2010 to 2013 the adoption of EHR will increase significantly worldwide and vary in different regions. For example, in North America, an increase of 9.7% is estimated. In the Asia Pacific region, it is anticipated to be at 7.6%. In Europe, Africa and Latin America, EHR adoption will increase by 6.6%. The total of these markets was estimated at $15.5 billion in 2010 and is projected to grow to $19.7 billion. A survey with primary care doctors in 10 countries [2] noted an overall increase in adoption of EHR and a significant variation in the growth rate across countries. For example, EHR adoption by doctors in the USA grew from 46% in 2009 to 69% in 2012, while in Germany the adoption growth rate was less significant: from 72% to 82% over the same period [2]. While increased adoption and growth of EHR markets has been observed, there is a surprising lack of studies of evidence-based EHR benefits. A literature review of EHR/electronic medical record (EMR) adoption in primary care [3, p. 22] observed: ‘no articles were found reviewing the benefits or drawbacks of health information systems accruing to patients should be concern to adopters, payers and jurisdictions’. We were hence motivated to develop a better understanding of the complexities and impacts of EHR systems implementation by systematically reviewing previously reported EHR implementations.
We adopt the revised version of DeLone and McLean's conceptual framework [4] to assess information quality, system quality, service quality, intention of use and usage, user satisfaction and net benefits; and we extend this framework to include various contingent factors such as development, implementation and organisational [5]. Therefore, our review not only assesses the impacts of EHR, but also identifies associated issues to better inform future EHR implementations.
The paper is structured as follows: the next section will present a definition of EHR and the conceptual framework adopted in this review. Next, the study design will be described. This will be followed by an analysis of the selected papers. The last two sections discuss the findings from the literature and draw conclusions and implications for future EHR implementations and research.