Review
Electronic health records implementation: An evaluation of information system impact and contingency factors

https://doi.org/10.1016/j.ijmedinf.2014.06.011Get rights and content

Highlights

  • A cumulative and up to date review of EHR implementations.

  • EHR adoption has grown with mixed perceptions about system quality and impacts. Contingency factors play an important role.

  • More research is needed into in patient accessible EHR.

  • EHR systems should support socio-technical connectives between the clinician, the patient, and innovative models of care.

  • Successful use of DeLone and McLean's framework with Van der Meijden's contingent factors.

Abstract

Objective

This paper provides a review of EHR (electronic health record) implementations around the world and reports on findings including benefits and issues associated with EHR implementation.

Materials and methods

A systematic literature review was conducted from peer-reviewed scholarly journal publications from the last 10 years (2001–2011). The search was conducted using various publication collections including: Scopus, Embase, Informit, Medline, Proquest Health and Medical Complete. This paper reports on our analysis of previous empirical studies of EHR implementations. We analysed data based on an extension of DeLone and McLean's information system (IS) evaluation framework. The extended framework integrates DeLone and McLean's dimensions, including information quality, system quality, service quality, intention of use and usage, user satisfaction and net benefits, together with contingent dimensions, including systems development, implementation attributes and organisational aspects, as identified by Van der Meijden and colleagues.

Results

A mix of evidence-based positive and negative impacts of EHR was found across different evaluation dimensions. In addition, a number of contingent factors were found to contribute to successful implementation of EHR.

Limitations

This review does not include white papers or industry surveys, non-English papers, or those published outside the review time period.

Conclusion

This review confirms the potential of this technology to aid patient care and clinical documentation; for example, in improved documentation quality, increased administration efficiency, as well as better quality, safety and coordination of care. Common negative impacts include changes to workflow and work disruption. Mixed observations were found on EHR quality, adoption and satisfaction. The review warns future implementers of EHR to carefully undertake the technology implementation exercise. The review also informs healthcare providers of contingent factors that potentially affect EHR development and implementation in an organisational setting. Our findings suggest a lack of socio-technical connectives between the clinician, the patient and the technology in developing and implementing EHR and future developments in patient-accessible EHR. In addition, a synthesis of DeLone and McLean's framework and Van der Meijden and colleagues’ contingent factors has been found useful in comprehensively understanding and evaluating EHR implementations.

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.

Section snippets

Electronic health records and types of electronic health record

A concise meaning or classification of EHR is difficult to articulate. Having reviewed the literature in EHR, Hayrinen et al. [6] found that EHR performs a multitude of functions utilising different types of data. According to the International Organization for Standardization ISO/TR 20514:2005 [7] an EHR is ‘a repository of information regarding the health status of a subject of care, in computer processable form’ [7]. Our paper refers to an EHR as a virtual record of every health-related

Data collection

We selected relevant papers from a large collection of journal papers in 56 journals retrieved from the Scopus, Embase, Informit, Medline and Proquest Health and Medical Complete databases, dated 2001–2011 inclusive. Our search criteria focused on EHR implementations in healthcare. The search query was (health records OR medical records OR patient records OR healthcare records OR clinical records) AND (electronic OR digital) AND implementation. Exclusion criteria include industry papers,

Results

Our search identified 98 relevant papers for full review. These papers reported on single or multiple implementations across different healthcare contexts and providers. We included these articles in our analysis to take into account different perspectives and considerations.

Summary and discussion of impact evaluation

Based on an extension of DeLone and McLean's [4] evaluation framework, this systematic review has updated our knowledge and revealed insights into the impacts of EHR implementation worldwide. These are discussed below.

Conclusions

The paper presents the findings from a systematic literature review of the impact of EHR implementation in research publications from 2001 to 2011. While the paper builds upon previous reviews [5], [6], it differs from them in its focus on the impact of EHR implementation, the recent period for paper selection, and its application of DeLone and McLean's revised evaluation framework [4] extended with contingent factors [5]. The review shows that EHR adoption is rather low but continues to grow:

Author contributions

All authors (Lemai Nguyen, Emilia Bellucci, and Linh Nguyen) collaborated on the protocol and proforma, read abstracts and selected papers for full text assessment. Lemai Nguyen and Emilia Bellucci reviewed and analysed 98 selected papers and developed the full manuscript.

Competing interests

The authors declare that they have no competing interests.

Summary points

What was already known before this study:

  • EHR systems are being implemented and used to varying degrees of satisfaction and success.

  • Many providers are not well informed about the benefits of EHR, or are not confident in their implementation.

What this study has added to our knowledge:

  • The review shows that EHR implementations are on-going to various levels of acceptance and success. EHR are still predominantly used in

Acknowledgements

The authors would like to thank the editor and anonymous reviewers for their valuable feedback and suggestions in improving the clarity and readability of the paper.

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